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introduction to increase survey accuracy research designers now place considerable emphasis on developing better survey instruments however although the quality of the question items is a key determinant of overall survey quality and ethicality interviewer behaviour is a key factor often overlooked in practical assessments of survey data quality nevertheless numerous studies have shown interviewers impact on data quality and survey cooperation as a function of their personal characteristics and experience their psychological dispositions such k bell • e fahmy • d gordon school for policy studies university of bristol 8 priory road bristol bs8 1tz uk email as their expectations perceptions and motives and their behaviour including their method of communication in this paper we focus on the last of these interviewer effectsinterviewer behaviour there is substantial evidence to indicate that the behaviour of survey interviewers influences not only whether answers will be accurate and honest but also whether respondents will agree to answer survey questions at all and whether or not there are negative impacts from respondents involvement in the research a growing realisation of the importance of interviewer behaviour on survey response has reinforced a preference for standardised interviewing techniques over conversational interviewing methods so that the researcher can maintain control over the interviewerrespondent interaction where conversational interviewing is still encouraged there remains an ongoing and unresolved debate regarding the most appropriate interviewer behaviour for enhancing survey accuracy cooperation and ethicality hence we discuss both the extent and content of interviewer effects and link this to key debates regarding standardised versus flexible interviewing and appropriate conversational techniques such as building rapport the extent and nature of interviewers deviations from the standardised scripts are then explored and illustrated by drawing upon interview paradata collected as part of the 2012 uk poverty and social exclusion survey this analysis reveals that deviations from the standardised approach are widespread and that some unscripted conversations may undermine the accuracy or comprehensiveness of responses or even be potentially harmful to respondents we then go on to offer some concluding observations on the implications of our findings for research practice in terms of further survey interviewer training and for wider methodological debates concerning the dichotomisation of quantitative and qualitative techniques standardised versus flexible interviewing with standardised interviewing interviewers are required to read questions exactly as written probing is expected to be nondirective and feedback to be as neutral as possible for example when respondents seek clarification they will be offered standardised responses such as please answer according to your understanding of this term standardised interviewing is considered to reduce interviewer related error through ensuring that all respondents are asked identically worded questions without unscripted commentary that could bias answers from a more practical perspective it is also argued that standardised interviewing reduces costs by minimizing the interview length interviewer training time and coding time for these reasons most survey organisations maintain a strong preference for standardisation and data is collected using scripted interviews however fowler and mangione have suggested that interview standardisation could also constrain the development of rapport between interviewer and respondent they consider that it is difficult to administer household surveys in a completely standardised way since some conversational interaction between interviewer and respondent is essential furthermore conrad and schober assert that it is not possible to guarantee a uniform understanding of survey questions using a strictly standardised approach they argue that less structured forms of interviewing such as conversational interviewing often increase data accuracy because they facilitate standardisation of the meaning of questions which is not possible when interviewers adhere strictly to scripted questions in conversational interviewing the interviewer says what is necessary to help the respondents to correctly interpret the question conrad and schober found that conversational interviewing improves the accuracy of responses when interviewees circumstances are atypical respondents answer accurately about typical situations whether or not interviewers are licensed to clarify the concepts in the questions however when respondents answer about atypical situations their accuracy depends on whether or not they are able to get clarification from the interviewers when they cannot get this help they are very inaccurate when they can obtain it their accuracy improves the more flexibly the interviewers can provide help the more it improves response accuracy similarly dykema et al found that interviewers who change question wording obtain more accurate answers when the questions are more complex than those who do not and suggest that interviewers predict which problems may be problematic and alter these questions in advance so as to ensure a correct interpretation respondents may not seek clarification when required so it may be helpful if interviewers identify verbal or nonverbal signs that respondents need clarification even where this is not explicitly requested furthermore flexibility when interviewing appears productive in gaining cooperation interviewers that are good at soliciting cooperation from respondents are usually also skilled at tailoring their approach to the situation whether flexible or standardised interviewing is the aim it seems that in practice survey interviewers frequently deviate from the scripted wording some of these deviations appear to be unhelpful including failing to ask some scheduled questions giving feedback which could influence future responses and using directive probes for example interviewers sometimes give positive feedback even when respondents do not give adequate answers so as to maintain a harmonious interaction some studies show that the more experience interviewers gain the more likely they are to deliver survey questionnaires in a less standardised way in particular they are more likely to omit parts of questions add words and phrases give improper feedback and not follow up with probes in response to uncertainty yet they are also more likely to engage in rapport develop better communication strategies and adopt a more relaxed interviewing style than less experienced researchers therefore flexible interviewing continues to be practiced in spite of the pressure to use standardised techniques skilled interviewing may therefore be more important than rigidly adhering to a particular technique belli et al found that significant deviations from the survey script or not following up with a necessary probe was linked to poor data quality whether standardised or flexible interviewing was the dominant technique hence it is important to consider not just the desirability of deviation from a standardised script but also the helpfulness or otherwise of the content of those deviations building rapport in structured interviews the ability to establish rapport is often considered to be one of the most important skills for effective interviewing however there is little consensus on how rapport should be defined in a survey context or how rapport affects survey responses capella describes rapport as a feeling of connection mutual comfort and conversational ease gremler and gwinner describe rapport between interviewer and respondent in terms of chemistry and being in tune rapport can be established through a range of interviewer behaviours including highly attentive behaviour common grounding behaviour courteous behaviour connecting behaviour and information sharing behaviour the extent of rapport has been measured in a variety of ways including asking interviewers and respondents whether they felt comfortable during the interview and assessing respondent cooperation and interest davis et al whether rapport enhances data quality or not is also contested for example weiss argues that rapport results in response bias because it causes respondents to ingratiate themselves to interviewers encouraging distorted responses especially on sensitive questions in contrast holbrook et al argue that rapport reduces response bias by motivating respondents to engage more deeply with the interview and give thoughtful honest responses other researchers suggest that rapport has no systematic effect on data quality or that too little and too much rapport can be detrimental to data quality however appropriate sensitivity and adherence to everyday conversational norms is certainly necessary for any successful interview and this is especially apposite in relation to household surveys conducted in respondents homes research by lewis and graham shows that because being interviewed is an unfamiliar experience respondents look to interviewers to help them feel comfortable being at ease is important for data quality helping interviewees to answer honestly and openly and to understand information and remember accurately furthermore there is also an important ethical dimension to this discussion the subject matter of surveys can be sensitive and questions are often very personal so it is very important to respond appropriately in order to avoid causing unintended harm to respondents if a trauma is discussed with someone who is not empathic this can be psychologically harmful sensitivity and rapport also imply the need for flexibility the capacity to respond flexibly is also ethically important when administering household surveys that may unearth sensitive information since it is not possible to know in advance the kind of psychological associations that could be triggered by survey questions hence even in the administration of standardised survey instruments researcher sensitivity to potential problems of miscognition or psychological distress is necessary not least because such problems may not be explicitly voiced by respondents therefore survey interviewers must be skilled in building rapport and using conversational techniques even when expected to carry out standardised interviewing so as to adequately and ethically respond to the unpredictable interview situation and to ensure that any deviations from the scripted interaction are productive in achieving valid and accurate responses this implies that adequate training is imperative so as to equip the interviewers with sufficient skills in developing rapport and flexible interaction within the interview situation methodology in the following analyses we investigate the extent to which standardised interviewing protocols are in fact implemented and with what consequences for survey data quality and ethical research practice the research drew on paradata defined as additional data that can be captured during the process of producing a survey statistic paradata include the biproducts of computerassisted technology audio recordings of the survey interview and interviewers handwritten notes there has been a rapid growth in the production and use of paradata over the last ten years perhaps because researchers are now less likely to have direct contact with field interviewers and therefore may be less likely to receive information about the conduct of fieldwork most survey data collection is contracted out and researchers are unable to influence the choice of interviewers or their training studying and analysing paradata is one way that we can find out more about the process in this paper we draw on interview transcript paradata collected as part of the 2012 poverty and social exclusion in the united kingdom main survey the pseuk project included a household survey which reinterviewed respondents to the 20102011 family resources survey it was conducted on behalf of the university of bristol heriotwatt university the open university queens university belfast university of glasgow and the university of york by the national centre for social research in britain and the northern ireland statistics and research agency the survey aims to improve the measurement of poverty deprivation social exclusion and living standards and on this basis to measure change in the nature and extent of poverty and social exclusion in the uk since 1999 although only a single study is examined here the field interviewers employed by the survey organisation for this study work on a variety of national household surveys and we believe our findings are likely to be indicative of wider research practice in this area the pseuk study used a standardised data collection method although encouraging building rapport at the initial doorstep encounter the pseuk survey organisation instructed interviewers to take a rigorously standardised approach during the interview for example interviewers were instructed to • ask the questions exactly as writtendo not change any words… • read out the whole question right to the end which is defined by the question mark… • never add anything to the question • ask in the order on the questionnaire… • ask every question on your routenever miss out a question because you think it inappropriate after securing the consent of respondents and interviewers a sample of 23 survey interviews were selected by the administering organisation for audiorecording since all the interviewers that agreed to participate were experienced the sample was not randomly selected and this has been taken into account in the analysis after audiorecording the process of administering these 23 surveys the recordings were transcribed and anonymised we then examined the extent and content of deviations from the scripted interview though behaviour coding of interviewer behaviour and framework analysis as outlined below behaviour coding as well as helping to determine the effectiveness of the survey instrument behaviour coding can also be used to enable researchers to learn more about how interviewers are performing the task behaviour coding approaches involve the application of a systematic coding framework to survey interview data the procedure examines interviewerrespondent interactions and within this research paradigm problem free interactions are assumed to be those where interviewers read survey questions verbatim and respondents provided a codeable answer as willis notes concerns have been raised about the subjectivity of the behaviour coding process it is possible to offset this to some extent by using multiple coders and assessing the degree of interrater consistency or by taking extensive notes of decisions made however it must still be acknowledged that some degree of subjectivity is inherent to the behaviour coding process the behaviour codes used here were developed by amalgamating and adapting the coding frames used in previous behaviourcoding studies the 23 interview transcripts were coded by a single researcher using the notetaking method table 1 shows the behaviour coding that was applied to the interviewers behaviour as recorded in the interview transcipts framework analysis framework analysis was used to conduct textual analysis of the interview transcripts implemented using proprietary nvivo framework software the distinctive aspect of framework analysis is that it allows themes to develop from the research questions the reviewed literature and the narratives of research participants the process involved a number of distinct interconnected stages familiarisation with the data identifying themes indexing charting and interpreting the first stage familiarisation with the data was facilitated by behaviour coding all the transcripts initially the second stage involved identifying themes in the data using a hybrid of thematic analysis approaches incorporating the inductive approach of boyatzis and the deductive technique outlined by crabtree and miller boyatzis approach involves a preliminary coding process to organize the data and themes are then developed from these codes crabtree and millers technique involves identifying codes in advance based on existing theory and evidence as well as a preliminary scanning of the text the third and fourth stages indexing and charting were facilitated by the nvivo programme the final stage interpreting the data involved using seven established criteria for interpreting coded data considering meaning context internal consistency frequency and extensiveness of comments specificity of comments intensity of comments and how data relate to the bigger picture results behaviour coding table 2 below shows the results of behaviour coding interviewers behaviours the results demonstrate the variability in how strictly interviewers adhered to standardised interviewing protocols with some closely following the scripted behaviour and other interviewers regularly deviating from the script and engaging in numerous digressions to summarise of the 1635 questions asked 55 were read with the exact wording 37 were read with a slight change 7 were read with a major change and 16 were skipped when a probe was used in 52 of cases it was a nondirective probe as considered to be ideal but 48 of the time a directive probe was used when a clarification was made in response to a request 79 of the time it was adequate and 21 of the time it was inadequate on 18 of occasions the response to the question was inadequately interpreted several authors propose that in standardised interviewing nonideal interviewer behaviour should occur no more than 15 of the time in this analysis nonideal interviewer behaviour occurred 99 of the time the range was between 0 and 27 indicating a wide variation of behaviours between the interviewer though most fell below the 15 threshold a slight change to the question was classified with exact wording because the kinds of changes were minimal and did not affect meaning at all we focus here on interviewer behaviour only to ascertain the extent of deviation from a script and in combination with framework analysis we examine the nature of those deviations though there was a range of interviewer behaviours the behaviour coding results suggest that in general the interviewers tended to make frequent deviations from the scripted questions even though they were given explicit instructions to use standardised methods this level of flexibility is considered to be acceptable according to the literature with the overall average percentage of deviation from the script falling below the 15 threshold framework analysis with an overview of the extent of conversational diversion available to us from the behaviour coding we then used a framework analysis of the transcripts to illuminate the content of these conversational diversions our interpretation reflects observable behaviour only since the motives for conversational behaviour cannot be readily ascertained however it is evident from this analysis that interviewers engaged in a range of conversational behaviours that were not directly relevant to answering the questions including giving emotional support giving advice or information complimenting the participant making jokes sharing the research process and revealing personal information we briefly describe and illustrate these below before reflecting on their wider significance in the concluding section giving emotional support in the 23 sample interviews the interviewer was often appropriately responsive to the emotional material that arose and at times gave significant support to the participant for example in this excerpt the interviewer gave the respondent plenty of space to talk and validated their feelings about some distressing news if it was yesterday i sudden was it sudden… though this interviewer rarely deviated from the scripted interaction she was able to be flexible when required however interviewers did not always display appropriate sensitivity or flexibility for example in the following exchange the interviewer moves on when a traumatic event is referred to and does not appear to respond at all perhaps this interviewer demonstrated empathy nonverbally through tone of voice and expression relying on written transcripts meant that this nonverbal behaviour was not available to us we also do not know the overall context as clearly the interviewee had spoken about this during a previous interview however these words alone suggest little if any rapport sensitivity or flexibility in this encounter this interviewer did show a remarkably low level of deviation from the script overall which perhaps indicates that their main concern was to carry out the standardised instructions they had been given bearing in mind that a lack of empathy in response to the disclosure of a traumatic event can be harmful this interview cannot be considered to be adequate or ethical if this interviewee were retraumatised by these comments they may well be unlikely to feel motivated to disclose any other information that could leave them feeling vulnerable moreover this example also illustrates that the way surveys are administered does not just pertain to data quality it is also an issue of ethical conduct and common human decency giving advice or information this area of conversation included giving advice about financial matters making proposals about how to resolve disagreements with neighbours passing on ideas for entertaining children and giving advice about how to lobby the council for better services for example in the following interview advice is given regarding a financial matter relating to household insurance i oh theyre nice clocks as well arent they nice ones have you had them valued m no no i havent had them valued i it might be an idea m yeah i itll invalidate your contents insurance m oh right okay i i was told that the other day if youve got something thats not that you havent mentioned not only do they not pay out but they dont pay out at all m oh right oh okay i i havent checked that out but it came from quite a reliable source you know somebody in sort of financial services he said its wrong m theres a loophole for everything isnt there i yeah so… m ill look in to that commonly where both interviewer and respondent were parents information and advice was given regarding caring for children in this sample the interviewer gave information andor advice on school issues relating to children at different life stages hobbies and affordable places to go with children here for example the interviewer discusses ideas for economically entertaining children i and i mean its chipwrecked at the moment and we went we paid full price to see it and it was like £24 we could have gone for you can get the vip we go in the vip seats and for three of us its £885 or something like that so thats on every saturday and sunday at 1030 f oh right m yeah i thats a really good cheap… hence here the interviewer engaged in several of the commonly recognised ways of building rapport ie common grounding behaviour connecting behaviour and information sharing behaviour whether building rapport was the interviewers conscious motivation or not we might assume that this diversion would have such an impact complimenting the participant this kind of conversation involved recognising and praising the participant in relation to their home their children and their skills for example in interview 6 the interviewer said here again the interviewer engages in behaviour which tends to encourage rapport such as very attentive and connecting behaviours if rapport enhances data quality then we could assume this diversion from the script to have helped the data collection process this is not to imply that the interviewer was being manipulative but rather engaging in the natural bonding behaviour that occurs when humans interact making jokes jokes and humour occurred throughout many of the 23 sampled interviews the jokes were initiated by the interviewer or the respondent and continued in humorous banter this excerpt from one conversation is typical humour is a common feature of building and sustaining rapport it is also well known for reducing stress which most would consider helpful to data collection because stress undermines the cognition and recall therefore we could assume that stress relieving laughter would increase data quality as both interviewer and interviewee will be more able to think clearly despite discussing sensitive topics sharing the research process another category of conversation could be described as sharing the research process this included expressing frustrations about the work discussing the process of carrying out the survey including mistakes made in the past talking about findings from the survey and providing some background about the survey development for example in relation to expressing frustration about the work one interviewer answered a question from the respondent in the following way f how many people will you be seeing tonight i oh well if that computers giving me a bit of jip ill… ill call it a draw i still say theres something wrong with it and they keep saying oh its just the security every computer ive the one before that was brilliant it used to start up in no time and… f yeah i …never had any trouble with it this one keeps freezing f not fun is it i no no i mean if it was my own i might just throw it from somebodys somebodys window in relation to talking about the study findings this appeared to be undertaken in order to try to help the respondent think about or understand the question however sometimes the comments made could be considered to be leading the respondent for example in the following interaction an interviewer said i by approximately how much has your income decreased since you were last interviewed f thats a really difficult one to answer i give a best estimate really what theyre trying to do is get i mean most people are saying their housing costs have increased literally all the ones ive interviewed and then most people have either stayed the same or decreased income wise so obviously thats a double double effect then a particular aspect of conversation that could become undermine data quality occurred where the interviewers referred to other interviews they had undertaken natcen instructs their interviewers in ethical research practice stating that interviewers should respect confidentiality and take care that in casual conversations they do not repeat interesting tales about respondents in spite of this on this occasion the interviewer made the respondent they were talking about identifiable i i interviewed a family of four yesterday and they werent on in a great area what do they call like a council house two children living at home but they were all working and no benefits at all which is really unusual not even child benefit because the children were too old and erm… f its not that unusual because when we were growing up thats what happened to us i its very unusual now f laughs is it i i interview 40 or 50 households a month and its very unusual very very unusual and erm but i mean one was the daughter was a team leader of 30 odd in this pick and pack place for name of workplace and had to work bank holidays as unpaid one shift every bank holiday is unpaid and take home £1400£1500 a month its a lot of work for… sometimes the interviewer even referred somewhat derogatively to other interviewees for example on this occasion one interviewer said i excellent that was very quick…this is my last one tonight if id have had that man as my last one… f youd still be doing it i you cant really if they want to talk you know hes got a few problems and if he wants to talk then you sort of feel half obliged to listen f oh yes especially when theyre on their own i but this is great for a last one somebody decisive therefore on these occasions sharing the research process may have undermined survey data quality it may have provoked mistrust on the part of the interviewee as they wondered what might be repeated or said about themselves again though it is not just a question of data quality there is an ethical dimension though the flexibility to digress from rigid standardisation seems important as earlier examples illustrate this has to be done skilfully in order to ensure the greatest degree of accuracy of the survey and to avoid causing harm to research participants revealing personal information some commentators argue that interviewers should share information about themselves with participants as this helps to equalise the researcherparticipant relationship and create rapport others have found that research participants while finding it helpful if the interviewers personality comes across do not want the interviewer to share personal information with them in the latter study respondents to household surveys felt that knowing something personal about the interviewer might influence the answers they gave and increase their desire to withhold information natcens interviewers training manual explicitly states that the interviewer should take care when asked questions about themselves because their answers could bias the results they are encouraged to give a noncommittal reply when this happens and encourage the respondent to talk about themselves again nevertheless personal information was often revealed by the interviewers that we audiorecorded although the reasons were not always obvious in general it seemed to be an attempt to put the respondent at ease perhaps as a subconscious interviewer strategy to help to promote some balance in the interaction in terms of the extent of personal selfdisclosure some of the revelations included anecdotes about personal failures perhaps to encourage the respondent to feel less intimidated or more willing to openup at times revealing personal information seemed to be an attempt to establish some common ground though this is considered an effective way to build rapport sometimes this strategy can at times appear somewhat desperate thereby undermining rapport as in the following example i how old is this one m shes shell be six in july i oh yes they do that sometimes the dialogue seemed to be a form of nervous chatting or thinking aloud since some of the discussion elicited no obvious interest from the respondent for example in the following extract without being asked any question on the topic the interviewer spontaneously began to talk about his cars whether these personally revealing interactions helped or hindered the interview process is hard to establish but at face value they do not seem to help in establishing and maintaining rapport as they seemed to be out of synch with the needs of the respondent despite being given strict instructions to take a standardised approach these experienced interviewers introduced a great deal of unscripted conversation and often deviated from the exact question wording the framework analysis themes correspond closely to the themes identified in the literature on rapport building ie very attentive behaviour common grounding behaviour courteous connecting behaviour and information sharing behaviour hence we could assume that the interviewers were attempting to build rapport or perhaps just being themselves so as not to introduce too much artificiality with accompanying tension to the process sometimes this may have helped the interview to flow more naturally but occasionally the interviewer seemed to behave in ways that were potentially harmful both to the research and to the participant discussion conclusion and implications various degrees of purely conversational or standardised interviewing techniques are available to survey researchers both techniques may improve response accuracy in some circumstances but there are always associated costs conversational interviewing clearly increases the duration of interview it can also mean that training the interviewer can take longer so as to ensure that they really understand the nature of the survey and the concepts being used yet with standardised interviewing questions may be misinterpreted and it is more difficult to answer accurately where there are atypical situations as outlined earlier some suggest that conversational interviewing with its emphasis on rapport motivates respondents to answer more openly and honestly and others argue that it encourages respondents to ingratiate themselves with interviewers and choose answers that will avoid embarrassment although this analysis is not informative regarding the impact of interviewing technique on survey response it does illustrate the wide variety of interviewing approaches adopted in the field even when interviewers are instructed to use standardised interviewing whether conversational or standardised approaches are adopted interviewer skill is clearly vital in promoting response accuracy in facilitating respondents cooperation and in safeguarding the ethical conduct of survey research whilst insensitive behaviour by interviewers may be rare it is somewhat concerning that this is evident in such a small sample and among interviewers who had consented to being recorded this emphasises the need for further monitoring and evaluation of the content of standardised interview conversations and the importance of training in conversational techniques for field interviewers even when delivering standardised questionnaires however several potentially confounding factors need to be noted with regard to interpreting the data firstly we do not know whether the approach used when the interview was audiorecorded was the interviewers usual style or their reaction to the specific respondent we did not collect data on the range of behaviour of the individual interviewers which would provide information on this secondly although interviewers were nonrandomly selected and experienced the potential biases this may introduce are unknown thirdly the interviews were recorded potentially introducing a number of related interviewer effects into the process the interviewers may have been more motivated to read the questions exactly as worded and to behave more consistently with the expectations of researchers to be neutral friendly and professional than they normally would be since they were conscious of being monitored given that we were observing the practices of experienced interviewers who were aware of being monitored we might expect more adherence to the instructions to carry out standardised interviewing than is generally the case yet interviewer digression was extensive and not always skilled therefore it is possible that the extent of sometimes inappropriate interviewer deviation from the scripted interaction is in fact even more common than suggested here having identified the extent and content of interviewer digression we do not advocate a more standardised approach all of the interviewers sampled at some point took a conversational approach and this was often carried out in a skilled manner some of their comments were leading and insensitive possibly impacting on survey reliability furthermore on occasion their comments appeared to be insensitive to the point of possibly being harmful to the respondent the survey organisations training appeared to focus primarily on developing interviewers standardised interviewing skills as a way of averting potential problems relating to reliability and ethicality this may have left interviewers insufficiently prepared with regard to situations where more conversational interviewing skills were needed the requisite flexibility which would have helped to enhance reliability and ethicality in those moments was therefore occasionally lacking whilst it could be argued that the problem is more in relation to the interviewers not following the instructions they were given than the training itself we would assert that the training should be sufficiently thorough that the interviewers are aware of the importance and meaning of confidentiality and rapport etc we might assume that they thought their interview technique was adequate since they were on this occasion being monitored and so their lapses were a result of a lack of information rather than a lack of will the interviewers seemed to be attempting to use standardised procedures that were inadequate for the some of the situations that they faced because of the aforementioned emphasis on developing the ideal survey instrument it is understandable that survey administration organisations should focus on training their interviewers to conduct standardised interviews yet the analysis carried out here underlines the importance of building appropriate rapport in interviewerrespondent interactions in a survey setting therefore survey administration organisations may want to consider the extent to which existing interviewer training provides sufficient weight to the development of the kinds of conversational interviewing techniques necessary to developing and maintaining rapport they may also wish to consider retraining more experienced interviewers as these may be more likely to make inappropriate comments this paper highlights the complex rapport and sensitivity skills that field researchers require even when administering standardised surveys it therefore contradicts a trend towards eliminating interviewer effects through virtual human interviewing foucault et al for example argue that preliminary evidence suggests that virtual human interviewers increase the likelihood that respondents will agree to participate in and complete webbased surveys and give honest accurate responses to even sensitive survey questions these authors suggest that if virtual human survey interviewers are to be truly effective we need to better understand how virtual humans should interact with real human respondents such a proposal ignores the apparent need for flexibility in interviews that we have highlighted in this paper however what may be rapport for one respondent could be perceived as overfriendliness by another what may be aloof behaviour for some could be interpreted as professional neutrality by others lewis and graham found that to avoid a negative interview experience research participants emphasised the importance of the interviewers ability to respond effectively to the specific individual and particular situation the research participants particularly found it hard to give advice about how the interviewer should respond when someone became upset as they felt this required the utmost sensitivity to the particular situation survey interviewers are required to be attentive to what is said the context and even the largely nonverbal even subconscious messages are being transmitted by the respondent all this requires a greater degree of sensitivity skill and flexibility than virtual humans can achieve according to the turing test the analysis outlined in this paper shows that this degree of skill and sensitivity is sometimes difficult even for real humans to achieve therefore as an additional observation we do not think virtual human interviewing is the way forward for increased accuracy cooperation and ethicality in household surveys another implication of this study relates to the perceived division between quantitative and qualitative methodologies despite continuing attempts to see the two as paradigmatically different and based on incommensurate ontological epistemological and methodological assumptions such divisions are increasingly seen as a false dichotomy we have provided an example of how quantitative data collection has qualitative elements and how these qualitative elements can be quantified in current research practice this traditional qualitativequantitative division is breaking down rapidly facilitated by technological innovation many computerassisted qualitative data analysis software programs now not only enable qualitative coding to be carried out but also allow the material to be exported to quantitative software programs for subsequent statistical analysis at the same time statistical software developers are now developing text analysis programmes some researchers now advocate that we teach research methodology courses without dividing quantitative and qualitative methods and they even propose removing the q words from textbooks in this vein greene and hall argue to use the qualitative and quantitative labels for paradigms is to reify and essentialize them and thereby disregard their constructed nature and discount the diverse histories and social locations of different kinds of qualitative and quantitative inquiry recognising the value of using both quantitative and qualitative methods numerous studies now employ both techniques the pseuk project itself does so however it is evident that there are qualitative aspects of the quantitative and quantitative aspects of the qualitative even within mixedmethods studies quantitative research when viewed as a distinct paradigm from qualitative research is often linked to the assumption that it is independent of the inquirer it is generally considered that the data is undistorted by contexts that are not included as variables this paper illustrates how quantitative research struggles to achieve this and therefore is closer to qualitative research than is generally recognised perhaps it is ultimately time to fully acknowledge the existence and value of qualitative computations and quantitative conversations open access this article is distributed under the terms of the creative commons attribution license which permits any use distribution and reproduction in any medium provided the original author and the source are credited

when developing household surveys much emphasis is understandably placed on developing survey instruments that can elicit accurate and comparable responses in order to ensure that carefully crafted questions are not undermined by interviewer effects standardised interviewing tends to be utilised in preference to conversational techniques however by drawing on a behaviour coding analysis of survey paradata arising from the 2012 uk poverty and social exclusion survey we show that in practice standardised survey interviewing often involves extensive unscripted conversation between the interviewer and the respondent whilst these interactions can enhance response accuracy cooperation and ethicality unscripted conversations can also be problematic in terms of survey reliability and the ethical conduct of survey interviews as well as raising more basic epistemological questions concerning the degree of standardisation typically assumed within survey research we conclude that better training in conversational techniques is necessary even when applying standardised interviewing methodologies we also draw out some theoretical implications regarding the usefulness of the qualitativequantitative dichotomy

introduction and rationale despite advances in prevention hivaids remains a serious public health concern among women around the globe with seroprevalence variation by geographic location age race ethnicity and other factors epidemiological data for the new york city metropolitan area indicate that the rate of hiv diagnosis was 150 per 100000 women in 2011 which reflects a decrease from the prior year however while there has been a decrease in the annual number of women diagnosed with hiv the proportion of hiv diagnoses attributable to heterosexual transmission has increased the percentage of reported hiv diagnoses for women in new york city attributed to heterosexual transmission was 456 in 2001 and 781 in 2011 the percentage attributed to injection drug use went from 148 to 37 at these same time points the continued risk for women associated with heterosexual transmission demands further examination particularly among women with substance use problems who often experience multiple hiv sexual risk factors readily apparent factors include substance use with sexual activity which negatively affects safer sex practices involvement with intimate partners who are at high risk for hiv and diminished relational power to request condom use by partners additional risk factors include this groups high rates of posttraumatic stress disorder and exposure to traumatic events which are associated with increased hiv sexual risk behavior among women more specifically prior estimates have shown that approximately 29 of women in methadone treatment in new york city experience ptsd exceeding the general population of women in the us by 25 times approximately 90 experience lifetime exposure to intimate partner violence exceeding the general population of women in the us by 34 times approximately 58 experienced childhood sexual abuse exceeding the general population of women in the us by 134 times and approximately 22 are living with hiv exceeding the general population of women in new york city by 275 times these collective experiences underscore the numerous vulnerabilities experienced by women in methadone treatment and the critical need to examine and address factors associated with hiv sexual risk behavior among this population as a precipitant of ptsd intimate partner violence sexual exchanges for drugs money or other goods and early onset of substance use childhood sexual abuse may be an important distal factor in hiv risk among women with substance use problems numerous studies document a relationship between csa and hiv sexual risk behaviors among women in the community in clinics and in schools far fewer have examined this relationship exclusively among women experiencing substance use problems while not unanimous quantitative studies conducted exclusively with women experiencing problematic substance use or heavy substance use patterns generally find statisticallysignificant relationships between csa and hiv sexual risk behaviors however prior research with this population has not examined ways in which types and characteristics of csa may be differentially associated with hiv sexual risk behaviors and has yet to focus on a random sample of women in substance use treatment the absence of such research is notable given prior findings that csa types and characteristics are differentially associated with longterm risks including substance use and mental health problems among women with substance use problems for example csa involving force and family has been found to be associated with increased risk of ptsd among women in methadone treatment csa severity has been found to be associated with days of cocaine use among women who recently completed inpatient treatment for cocaine dependence these findings further support the importance of addressing this substantive gap in knowledge in this area in a review of 73 studies that examined relationships between csa and sexual risk behaviors senn carey and vanable note that the absence of a common definition of csa is a major limitation in the body of knowledge regarding relationships between csa and hiv sexual risk behaviors definitional requirements regarding age at the time of sexual activity type of relationship and age differences between those involved in the sexual activity type of sexual activity the presence of force and the coding of csa variables frequently differ across studies making it difficult to compare findings in this area this study aims to strengthen the existing body of knowledge and future efforts to achieve a common definition of csa by examining ways in which observed relationships between csa and hiv sexual risk behaviors among women in methadone treatment may differ depending on how csa is defined and coded it also aims to strengthen the existing body of knowledge by considering childhood physical abuse in the analyses as research has shown that this experience is often associated with both csa and hiv sexual risk behavior however it is frequently overlooked in csahiv sexual risk behavior research conceptual framework in order to explicate connections between csa and hiv sexual risk behaviors several models that conceptualize mediated relationships between csa and hiv risk have been proposed for example miller posits that csa contributes to problems related to substance use mental health and sexual risk taking which in turn contribute to increased hiv risk wyatt and colleagues describe the relationship between csa and sexual risks as mediated by mental health problems and revictimization the miller and wyatt et al models are augmented by malow and colleagues who postulate that in addition to substance use mental health problems and revictimization assertiveness and selfefficacy are also important mediators between csa and hiv sexual risk these conceptual models and prior empirical findings suggest that mental health concerns substance use and revictimization are likely to be key factors and potential mediators in the csahiv sexual risk relationship as such they should be included in analytic models that examine csahiv sexual risk behavior relationships it should be noted that although assertiveness and selfefficacy are not available in the current dataset prior research has found that depression is negatively associated with them including depression in the multiple regression models in the current study facilitates important examination of the role of depression in hiv sexual risk behaviors as well as a degree of statistical control for assertiveness and selfefficacy there are several additional individual relational and situational factors that are salient among women in substance use treatment and are associated with hiv sexual risk behavior these factors include ones hiv status partner hiv risk status cohabitation with partner social support recent incarceration and homelessness in recognition of prior empirical and conceptual work related to the csahiv sexual risk behavior relationship the current analyses draw upon a multisystemic conceptualization of the relationship between csa and hiv sexual risk behaviors this multisystemic conceptualization posits that individual factors such as hiv status mental health concerns and substance use relational factors such as exposure to intimate partner violence partners hiv risk status and social support and situational factors such as recent homelessness and incarceration are likely to be important covariates and potential mediators in the relationship between csa and hiv sexual risk behaviors among women in substance use treatment study aims informed by this studys multisystemic conceptual framework and the need to address substantive and methodological gaps in research in this area the primary aim of the current analyses is to examine associations between csa and hiv sexual risk behaviors and any differences in the observed relationships between csa and hiv sexual risk behaviors based on csa coding types and characteristics among a random sample of women in methadone treatment in new york city it is anticipated that csa involving force family and greater severity will be associated with increased hiv sexual risk behaviors as a secondary aim we examine mediation in csahiv sexual risk behavior relationships when indicated by findings from the primary analyses methods recruitment of random sample this study involves secondary analysis of baseline data from the womens health project which focused on intersections between problematic substance use intimate partner violence and hiv among women in methadone treatment in new york city to recruit a random sample of women in a large methadone treatment program the whp used random number generation in spss 70 and selected 753 of the 1708 women enrolled in the program between november and december 1997 a total of 559 women completed screening interviews to determine study eligibility 416 women were eligible and agreed to participate in the study women enrolled in methadone treatment for at least 3 months and involved in a sexual dating cohabitation childcare or economic relationship with someone described as a boyfriend girlfriend spouse regular sexual partner or father of their children in the past year were eligible to participate in the parent study a total of 26 women who reported all female main partners were excluded from the present analyses due to distinctions in their hiv sexual risk behaviors procedures data were collected between 1997 and 2000 following informed consent processes inperson interviews were conducted in english and spanish by trained female interviewers who administered interview questions and recorded participants responses the institutional review boards at columbia university and at the methadone treatment program approved the study measures childhood sexual abusethe childhood sexual abuse interview focuses on sexual activities at age 15 or younger and includes 11 items based on interview schedules by finkelhor and sgroi the full scale of 11 items has a cronbachs alpha of 87 with this sample six items inquire about touchingexposure three items inquire about penetration single items inquire about picturetaking and other sexual activity consistent with definitions used in prior research the activity was classified as abuse when it involved someone 5 or more years older force or a relative in order to examine ways in which csa coding types and characteristics affect the observed relationships between csa and hiv sexual risk behaviors csa was coded in three ways first we used dichotomous coding to reflect any experience of childhood sexual abuse across the 11 items of the csai second we used continuous coding of two csai subscales which emerged from factor analysis with varimax rotation touchingexposure and penetration third we created a 5level mutuallyexclusive categorical variable that assessed no sexual abuse sexual abuse with someone 5 or more years older sexual abuse involving force sexual abuse involving a relative and sexual abuse involving force and a relative in the final category 950 of the cases involved force and a relative simultaneously and 50 of the cases involved force and a relative across discrete events hiv sexual riskwe focused on two types of hiv sexual risk behaviors in the past six months first we included inconsistent condom use with up to three main partners to begin we dichotomized responses to questions regarding sexual activity in the past six months categorical response options ranged from not once in the past six months to 6 or more times per week or 150 or more times in the past six months next we dichotomized responses to separate questions regarding frequency of condom use with vaginal and anal sex responses of never less than half of the time about half of the time and more than half of the time were coded as inconsistent condom use and responses of always were coded as consistent condom use we then combined these responses to identify vaginal or anal sex with inconsistent male or female condom use as applicable for each type of sexual activity across up to three main partners the association between consistent condom use and reduced sexually transmitted infections among men and women seeking sti care supported this dichotomous coding of condom use second we included substance use with sexual activity across up to three main partners any report of vaginal anal or oral sex while high on or using any drug heroin crack or cocaine or after consuming 4 or more drinks was dichotomously coded as drug use with sexual activity for each substance covariates sociodemographic characteristicsbecause of associations between sociodemographic characteristics and hiv risk behaviors they are included in the multiple regression analyses in this study sociodemographic variables included participants age raceethnicity highest grade completed in school legal marital status and annualized average monthly income we used the log of annualized monthly income in the multiple logistic regression analyses due to the wide range of reported values for this variable posttraumatic stress disorderto measure ptsd we relied on the 49item posttraumatic stress diagnostic scale which follows dsmiv diagnostic criteria and has reported sensitivity of 820 and specificity of 767 depressionto measure depression we dichotomized scores on the widelyused brief symptom inventory depression subscale to reflect values that were above and below 1865 the published median value in psychiatric outpatient norms for women substance usebased on responses to substancespecific questions regarding frequency of use in the past 6 months any reported use of heroin cocaine crack marijuana nonprescription stimulants nonprescription narcotics or nonprescription tranquilizers hypnotics or barbiturates was coded as drug use in this dichotomous variable the same coding was applied to any alcohol use in the past 6 months years in methadone treatmenta single continuouslycoded question for how many years altogether have you been on methadone assessed years in methadone treatment intimate partner violenceacross up to three main partners any positive response on the sexual coercion physical assault injury and psychological aggression items of the revised conflict tactics scale was coded dichotomously to reflect presence of ipv childhood physical abuseto measure childhood physical abuse we drew upon two separate questions asking participants if before they were 18 years old they were punched pushed hit shoved kicked whipped beaten or suffered painful physical injuries all beyond what is considered discipline by parents caretaker or guardian or if they were choked strangled or threatened with a knife gun or any other weapon by parents caretaker or guardian affirmative responses to either of these questions were coded as childhood physical abuse hiv main partner hiv risk status and cohabitation with partnerparticipants selfreported responses to a question regarding the result of their most recent hiv test were coded dichotomously the presence of any of the following factors across up to three main partners was coded as partner risk hivpositive status other sexuallytransmitted disease in the past 6 months sexual activity with other partners sexual activity with someone who is hivpositive or uses injection drugs or sexual activity in exchange for money or drugs participants reports of living with a partner were dichotomously coded social supportwe dichotomously coded the 12item multidimensional scale of perceived social support to indicate agreement or strong agreement with having social support from family friends and a significant other cronbachs alpha of the 12item continuous scale with this sample is 88 incarceration and homelessnesstwo singleitem questions inquired about incarceration or homelessness in the last 6 months data analysis plan reliability analysis was conducted with fullyobserved data using ibm spss statistics version 20 multiple imputation of missing data was conducted with the ice program in statase 101 which was used for all descriptive and logistic regression analyses univariate analyses were conducted in order to describe the sample and identify prevalence of csa hiv sexual risk behaviors and covariates bivariate analyses were conducted to examine relationships between csa and hiv sexual risk behaviors for each of the three csa coding schemes described earlier in order to examine relationships between csa and hiv sexual risk behaviors while adjusting for potential confounders multiple logistic regression analyses were conducted a set of multiple logistic regression analyses predicting each hiv sexual risk behavior was conducted for each csa coding scheme while bonferroni correction is often applied when conducting multiple analyses its limitations and risk of inflating type ii errors prompted us to retain the conventional pvalue of 05 in these analyses analyses are displayed in tables 1234 we conducted subsequent path analyses using mplus version 71 when the comparison of bivariate and multiple logistic regression findings suggested the possibility of mediation in the csahiv sexual risk behavior relationship when the statistical significance of the csahiv sexual risk behavior relationship at the bivariate level was absent in the multiple logistic regression analyses we conducted path analysis in which statisticallysignificant predictors of the dependent variable were entered as possible mediators in each of these situations we examined three models 1 the direct effect of csa on the dependent variable 2 the direct effects of each of the potential mediators on the dependent variable and 3 a final model of the direct effects of csa on the potential mediators and on the dependent variable and indirect effects of csa on the dependent variable through the potential mediators a weighted least squares parameter estimate method was used due to the binary nature of the variables this method handles missing data as a function of the observed covariates and not the observed outcomes however all 390 participants were included in the path models the following fit indices and values indicating good fit were used chisquare statistic comparative fit index and root mean square error of approximation a nonsignificant chisquare value is generally useful in representing good fit for sample sizes 75200 however in larger samples the chisquare value is regularly statistically significant additionally it should be noted that rmsea estimates with small sample sizes and in particular small degrees of freedom often falsely indicate a poor fitting model further some scholars have argued that there are no golden rules for interpreting fit indices in order to test mediation bootstrap analyses were conducted resampling 5000 samples and examining the standardized confidence intervals of the indirect effects of csa on the dependent variable through the potential mediators the indirect effect is significant if zero is not included in the 95 confidence interval results sample characteristics as displayed in table 1 the majority of the participants were latinahispanic or african americanblack single never married involved with one main intimate partner and residing with an intimate partner approximately half of their main intimate partners were at risk for hiv participants mean age was 399 years mean level of education was 110 years and mean level of annual income was 10228 in the past 6 months 95 of the women were homeless and 59 were incarcerated more than half of the participants experienced csa and more than a quarter of the participants experienced csa involving force and family touchingexposure was the most prevalent type of csa affecting 518 of the participants childhood physical abuse was reported by 373 of the participants and most often cooccurred with csa more than threequarters of the participants experienced ipv in the past 6 months a total of 278 of participants met diagnostic criteria for ptsd and 149 experienced depression alcohol and drug use in the past 6 months was reported by 495 and 631 of the participants respectively as shown in table 1 the most common hiv sexual risk behavior in the past 6 months was inconsistent condom use with vaginal sex followed by sexual activity while high on or using any drug sexual activity while high on or using heroin sexual activity while high on or using crack or cocaine sexual activity after consuming 4 or more drinks and inconsistent condom use with anal sex csa coding scheme 1 dichotomouslycoded childhood sexual abuse and hiv sexual risk behaviors dichotomouslycoded csa significantly predicted just one hiv sexual risk behavior as displayed in table 2 at the bivariate level a statisticallysignificant relationship was found between dichotomouslycoded csa and drinking four or more drinks prior to sexual activity women who reported csa were nearly twice as likely to report drinking four or more drinks prior to sex this relationship became statistically insignificant in the multiple logistic regression analysis which prompted further analysis to test for possible mediation in this relationship path analysis was used to examine the following possible mediators having a partner at risk for hiv drug use and exposure to ipv the direct effect model indicated a significant direct relationship between csa and drinking four or more drinks prior to sexual activity however the model was justidentified and model fit could not be assessed 000 p 001 results of the indirect model indicated relatively poor fit with the data 1630 p 003 cfi 81 rmsea 09 with statisticallysignificant relationships between csa and having a partner with hiv risk and between having a partner with hiv risk and drinking four or more drinks prior to sex there were statisticallysignificant relationships between csa and ipv and between ipv and drinking four or more drinks prior to sex while the relationship between csa and drug use was not statistically significant the relationship between drug use and drinking four or more drinks prior to sex was statistically significant figure 1 illustrates the final model 1425 p 003 cfi 83 rmsea 10 the fit of this final model was poor and while not unexpected given the sample size and small degrees of freedom results should be interpreted with the fit in mind when having a main partner with hiv risk drug use and ipv were added to the model the direct relationship between csa and drinking four more drinks prior to sex was no longer statistically significant indicating that full mediation is present a statisticallysignificant positive relationship was found between csa and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex the indirect effect was significant indicating that having a main partner with hiv risk mediates the relationship between csa and drinking four or more drinks prior to sexual activity as in the indirect model a statisticallysignificant positive relationship was found between csa and ipv and between ipv and drinking four or more drinks prior to sex however in the final model the indirect effect was not statistically significant indicating that ipv is not a mediator finally csa did not significantly predict drug use however there was a significant positive relationship between drug use and drinking four or more drinks prior to sex thus having a partner with hiv risk was the only mediator in the relationship between csa and drinking four or more drinks prior to sex together all of the variables accounted for 25 of the variance in drinking four or more drinks prior to sexual activity csa coding scheme 2 childhood sexual abuse involving touchingexposure and penetration and hiv sexual risk behaviors csa involving touchingexposure was associated with increased risk of heroin use with sexual activity even when adjusting for potential confounders as indicated in table 3 csa involving touchingexposure or penetration was not associated with any other hiv sexual risk behaviors we examined csa coding scheme 3 childhood sexual abuse involving force a relative or someone five years older and hiv sexual risk behaviors the only statisticallysignificant findings in the relationships between this csa coding scheme and hiv sexual risk behaviors were as follows csa involving force and a relative and csa involving someone 5 or more years older than the participant were both associated with heightened risk of drinking four or more drinks prior to sexual activity as shown in table 4 when adjusting for potential confounders these relationships became statistically insignificant which prompted further analyses to test for mediation path analysis was again used to further examine whether having a main partner with hiv risk drug use and ipv mediates this relationship in two separate path analyses examining 1 csa involving force and a relative and 2 csa involving someone 5 years or older in order to test these models the 5level csa variable was dummy coded into two separate independent variables which were used in their respective models 1 indicating whether a participant had experienced csa involving force by a relative and 2 indicating whether the participant had experienced csa involving someone 5 years or older the direct effect model for csa involving force and a relative was justidentified 000 p 001 and indicated a significant direct relationship with drinking four or more drinks prior to sexual activity results of the indirect model 1787 p 001 cfi 74 rmsea 09 indicated a statisticallysignificant relationship between csa involving force and a relative and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex there was a statisticallysignificant relationship between ipv and drinking four or more drinks prior to sex and between drug use and drinking four or more drinks prior to sex csa involving force and a relative did not significantly predict drug use the final model examining both the direct and indirect paths is presented in figure 2 1517 p 002 cfi 81 rmsea 10 again model fit was poor though not surprising given the sample size and small degrees of freedom however the fit should be taken into consideration when interpreting the findings the direct relationship between csa involving force and a relative and drinking four more drinks prior to sexual activity remained statistically significant there was a statisticallysignificant relationship between csa involving force and relative and having a main partner with hiv risk and between having a main partner with hiv risk and drinking four or more drinks prior to sex the indirect effect was significant indicating that having a main partner with hiv risk partially mediates the relationship between csa involving force and a relative and drinking four or more drinks prior to sex additionally a statisticallysignificant positive direct relationship between ipv and drinking four or more drinks prior to sexual activity was found and between drug use and drinking four or more drinks prior to sex thus having a partner with hiv risk was the only mediator in the relationship between csa involving force and a relative and drinking four or more drinks prior to sex together all of the variables accounted for 26 of the variance in drinking four or more drinks prior to sex next we examined whether csa involving someone 5 or more years older was directly related to hiv sexual risk behaviors and whether that relationship was mediated by having a main partner with hiv risk substance use andor intimate partner violence in contrast to the findings of the bivariate logistic regression analyses findings of the direct path model found no statisticallysignificant direct relationship between csa involving someone 5 or more years older and drinking four or more drinks prior to sexual activity thus further path analysis to test for mediation was not pursued posthoc analyses childhood physical and sexual abuse and hiv sexual risk behaviors the analyses yielded unexpected findings regarding reduced risk of inconsistent condom use and nonspecific drug use with sexual activity among women who reported childhood physical abuse as displayed in tables 2 and3 to further understand these findings and the potential that childhood physical and sexual abuse may interact to influence them we conducted posthoc analyses to examine relationships between childhood physical abuse and sexual abuse alone and in combination and inconsistent condom use and drug use with sexual activity using a 4level categorical variable we found no statisticallysignificant relationships between childhood physical and sexual abuse alone or in combination and inconsistent condom use during vaginal sex or anal sex in the bivariate or multiple logistic regression analyses as with the models predicting inconsistent condom use with anal sex displayed in tables 2 3 and 4 this posthoc model also remained statistically insignificant additionally there were no statisticallysignificant relationships in the bivariate or multiple logistic regression analyses between childhood physical and sexual abuse alone or in combination and nonspecific drug use with sexual activity discussion this study is the first to our knowledge that examines ways in which csa coding type and characteristics may affect observed relationships between csa and hiv sexual risk behaviors among women in substance use treatment although it finds statisticallysignificant often mediated relationships between csa and hiv sexual risk behaviors with main intimate partners the findings regarding associations between csa and hiv sexual risk behaviors are more limited than anticipated particularly given the scope of analyses conducted there are multiple ways to understand these unexpected findings first prior research with women in methadone treatment also found no association between csa and condom use or number of male sex partners however it found that other factors including race alcohol use residing with a partner suicidality and hiv status predicted sexual risk behaviors similarly our findings point to the significance of residing with a partner alcohol use hivnegative status ipv exposure and lack of social support as key predictors of inconsistent condom use during vaginal sex with main intimate partners other individual relational and situational factors including depression alcohol and drug use having a partner with hiv risk and recent incarceration also differentially predicted having sex with main partners while under the influence of drugs or alcohol together with prior research with women in methadone treatment and women recruited from the community who used drugs our findings indicate that the role of csa in most of the hiv sexual risk behaviors examined in this study may be less salient than current psychological substance use relational and situational factors second it is possible that methodological issues influenced the findings this study focused only on sexual risk behaviors with main partners and considered these risks across three main partners it may be that associations between csa and sexual risk behaviors differ between main and secondary partners and that this differential association was not captured in our analyses additionally this study relied on dichotomouslycoded sexual risk variables it is possible that continuouslycoded sexual risk variables may yield different findings regarding relationships between csa and sexual risk behaviors with main partners finally this study collapsed all drug use into a single category which may have obscured the specific roles of different drugs in csasexual risk behavior relationships in contrast to expectations based on prior research this study found that touchingexposure and not penetration or other csa measures predicted increased risk of heroin use with sexual activity this unexpected finding suggests that unobserved contextual aspects of these experiences which may include age relationship frequency duration and circumstances of the touchingexposure have important bearing on the longterm sequelae of csa similar to findings by wyatt and peters that different definitions of csa result in variations in prevalence estimates this study indicates that definitional differences also affect findings regarding observed associations between csa and sexual risk behaviors further this study suggests that childhood sexual and physical abuse may interact in ways that are important to further understand in relation to hiv sexual risk behaviors among this population the most consistent finding regarding the csahiv sexual risk behavior relationship was the statistical significance of the association between csa and increased likelihood of drinking four or more drinks prior to sex with main partners this finding held with dichotomouslycoded csa and with csa involving force and a relative in both logistic regression and path analyses when dichotomously coded the csaheavy alcohol use prior to sex relationship was mediated by having a partner with hiv risk having a partner with hiv risk also partially mediated the relationship between csa involving force and a relative and heavy alcohol use prior to sexual activity drug use and ipv were not mediators but they were associated with drinking four or more drinks prior to sexual activity and the total combination of variables explained a considerable portion of the variance in consuming 4 or more drinks prior to sex there are several ways to understand the links between csa involvement with partners at risk for hiv and drinking four or more drinks prior to sex involvement with an intimate partner at high risk for hiv may reflect engagement in a highrisk social network and hindered ability to identify and address risks sexual or otherwise among women with histories of csa it may also reflect continuation of a highrisk sexual trajectory that was initiated through early sexual abuse additionally women may use alcohol prior to sex as a form of avoidant coping with their partners risks particularly when the threat of violence is present while these possibilities can facilitate understanding of the mediated relationship between csa and heavy alcohol use prior to sex there remains a need for additional research to further understand the relatively consistent associations between csa and heavy alcohol use prior to sex and the relatively limited associations between csa and drug use with sex among women in methadone treatment in this study ipv was the most consistent predictor of hiv sexual risk behavior this finding is consistent with prior crosssectional and longitudinal research among women in methadone treatment in the context of violence women may fear retaliation for requests to use condoms additionally they may use drugs and alcohol with sexual activity to manage psychological and physical trauma associated with victimization the findings underscore the critical importance of ongoing efforts to design and test interventions to address cooccurring substance use and ipv as part of hiv prevention this study makes novel contributions to understanding relationships between csa and sexual risk behaviors with main partners among women in methadone treatment however it is not without its limitations as discussed earlier and further addressed here while the multiple questions regarding types of sexual activities were a strength of the csa measure it relied on retrospective recall although events that occurred at sufficient age are likely to be recalled the personal nature of such disclosure may have resulted in underestimated csa prevalence in this study further emerging trends in reported hiv diagnoses among women in new york city indicate an overall decrease in the annual number of hiv diagnoses reported with a tenfold decrease in the number of women whose diagnoses were attributed to injection drug use between 2001and 2011 this studys data which were gathered between 1997 and 2000 may reflect higher hiv risks when compared to current data interpretation of study questions may have also affected the studys findings in particular the cpa items may have resulted in underestimates of cpa prevalence as one of the items involved participants making a determination regarding experiences that exceeded discipline finally the crosssectional data suggest caution when making causal inferences regarding the correlates of sexual risk behaviors and mediators in the csahiv relationships conclusion this study finds that csa type and characteristics are differentially associated with consuming four or more drinks prior to sexual activity and using heroin with sexual activity additionally the study finds that having a main partner with hiv risk mediates relationships between both any csa and csa involving force and a relative and drinking four or more drinks prior to sex although women with histories of csa are at heightened risk of having sex under the influence of alcohol and depending on the csa characteristics having sex under the influence of heroin the associations between csa and sexual risk behaviors are more limited than expected especially in light of the numerous analyses conducted in this study the findings suggest that ipv polysubstance use depression social support recent incarceration and relational contexts are salient factors in hiv sexual risk behaviors as such they highlight the critical importance of further research to develop and test multifaceted comprehensive approaches to hiv prevention among women in methadone treatment dr louisa gilbert is a licensed social worker with 25 years of experience developing implementing and testing multilevel interventions to address hivaids substance abuse trauma partner violence and other cooccurring issues among vulnerable communities in the us and central asia she has served as the codirector of the social intervention group since 1999 and the codirector of the global health research center of central asia since 2007 her specific area of research interest has concentrated on advancing a continuum of evidencebased interventions to prevent intimate partner violence among druginvolved women and women in the criminal justice system more recently her funded research has also focused on identifying and addressing structural and organizational barriers in harm reduction programs to implementing evidencebased interventions to prevent overdose among drug users in central asia katherine winham received her doctoral degree from the kent school of social work at the university of louisville where she was awarded the john m houchens prize for outstanding dissertation she is a practicing social worker and licensed marriage and family therapist and holds masters degrees in both fields with the goal of developing interventions her research focuses on investigating relationships between victimization experiences and physical and mental health outcomes and high risk behaviors among vulnerable and underserved populations especially women involved with the criminal justice system zimet gd dahlem nw zimet sg farley gk 1998 the multidimensional scale of perceived social support journal of personality assessment 523041 figure 1 final fitted path model with estimated regression coefficients for the direct path between csa and four or more drinks prior to sex and as mediated by main partner with risk drug use and intimate partner violence final fitted path model with estimated regression coefficients for the direct path between csa involving force and a relative and four or more drinks prior to sex and as mediated by main partner with risk drug use and intimate partner violence

backgroundchildhood sexual abuse csa is often considered an important distal factor in hiv sexual risk behaviors however there are limited and mixed findings regarding this relationship among women experiencing substance use problems additionally research with this population of women has yet to examine differences in observed csahiv sexual risk behaviors relationships by csa type and characteristics objectivesthis study examines relationships between csa coding type and characteristics and hiv sexual risk behaviors with main intimate partners among a random sample of 390 women in methadone treatment in new york city who completed individual interviews with trained female interviewers resultsfindings from logistic regression analyses indicate that csa predicts substance use with sexual activity with variations by csa coding type and characteristics however the role of csa is more limited than expected having a main partner with hiv risk mediates some relationships between csa and drinking four or more drinks prior to sex intimate partner violence is the most consistent predictor of sexual risk behaviors other salient factors include polysubstance use depression social support recent incarceration and relationship characteristics conclusionsimportancethe study contributes to understanding of relationships between csa and hiv sexual risk behaviors and key correlates associated with hiv sexual risk behaviors among women in methadone treatment it also highlights the complexity of measuring csa and its association with sexual risk behaviors and the importance of comprehensive approaches to hiv prevention that address psychological relational situational and substance use experiences associated with sexual risk behaviors among this population

introduction cardiovascular diseases represent the leading cause of death in most countries where coronary heart disease and more specifically myocardial infarction is the most common cause of death among cvds 12 established risk factors for chd are hypertension smoking dyslipidaemia and diabetes 3 the addition of other modifiable risk factors including abdominal obesity psychosocial stress highrisk diet low physical activity and regular alcohol consumption account for 90 of the population attributable risk of mi as per the results of the interheart study 4 there is also strong evidence showing that the socioeconomic status at the individual and neighbourhood level shapes the cardiovascular risk factors of their residents 56 in fact neighbourhoodlevel ses has been shown to be an important risk factor for chd independent of individuallevel ses such as education level and marital status 7 both the incidence of mi and cardiovascular death has declined steeply in most developed countries in recent years 89 yet recent data from norway indicates that the incidence of mi has not decreased among younger middleaged adults and that acute mi hospitalisations have even increased among this group 10 recent national data from sweden points towards an increased incidence of mi during the last decade in women aged 3544 years 11 however whether the risk for chd among younger middleaged adults partly can be explained by neighbourhood ses has to the best of our knowledge not been explored therefore the objective of this study was to explore the relationship between neighbourhood ses and incident premature chd and mi in younger middleaged adults and whether that relationship is independent of individuallevel socioeconomic factors such as education level marital status immigrant status and region in sweden we hypothesised that the risk of mi and chd is higher among men and women living in lowses and middleses neighbourhoods than in those living in highses neighbourhoods methods data used in this study were retrieved from a national database that contains information on the entire population of sweden for a period of 40 years this database is based on several swedish registers and contains comprehensive nationwide individuallevel data as well as data on neighbourhood ses the registers used in the present study were the total population register and the national patient register the swedish nationwide population and healthcare registers have exceptionally high completeness and validity 12 individuals were tracked using the personal identification numbers which are assigned to each resident of sweden these identification numbers were replaced with serial numbers to provide anonymity the followup period ran from 1 january 1998 until hospitalisationoutpatient treatment of mi andor chd at the age of diagnosis before 50 years death emigration or the end of the study period on 31 december 2010 whichever came first neighbourhoodlevel ses the home addresses of all swedish individuals have been coded to small geographic units with boundaries defined by homogeneous types of buildings these neighbourhood areas called small areas for market statistics or sams each contain an average of 1000 residents and were created by the swedish governmentowned statistics bureau statistics sweden sams were used as proxies for neighbourhoods as they were in previous research 13 neighbourhood of residence is determined annually using the national land survey of sweden register a summary index was calculated to characterise neighbourhoodlevel deprivation the neighbourhood index was based on information about female and male residents aged 2064 years because this age group represents those who are among the most socioeconomically active in the population the neighbourhood index was based on four items low education level low income unemployment and receipt of social welfare the index for the year 2000 was used to categorise neighbourhood deprivation as low moderate and high 14 the neighbourhood ses each individual resided in at the age of 40 when the individuals entered the study was used as exposure in the present study neighbourhood level variables four categories of neighbourhood goods services and resources were selected the categories were 1 fastfood restaurants barspubs 3 physical activity facilities 4 healthcare facilities to obtain these data the readytouse nationwide gis dataset of business contacts for november 2005 was provided to us by the swedish company teleadress 13 individuallevel sociodemographic variables inclusion all individuals in sweden entered the cohort in the year of their 40th birthday if it occurred between 1998 and 2010 individuallevel sociodemographic variables of marital status educational level and region of residence were defined according to the year of inclusion in the study statistical analysis personyears were calculated from the start of the followup results in total 11 million men and women with a mean followup time of 55 years were included in the analysis at their 40th birthday 5 lower risks were seen among men and women living in highses neighbourhoods higher risks were observed in those living in lowses neighbourhoods when using middleses neighbourhoods as a referent group the risks were slightly attenuated but still significant when adjusted for marital status education level immigrant status and region of residence the results remained significant when further adjusted for neighbourhood goods and services and hospital diagnoses of diabetes and hypertension prior to the age of 40 years as a secondary analysis we performed a subgroup analysis of the risk of mi and chd in immigrants adjusting for marital status education level region of residence and number of years in sweden the risk estimates were similar to those found for the whole cohort for immigrants residing in high and low ses when using middle ses as referents hr for men in high versus middleses neighbourhoods mi 058 and chd 064 hr for men residing in lowses versus middleses neighbourhoods mi 126 and chd 130 for women the results were nonsignificant discussion in the present study where all individuals residing in sweden were included at their 40th birthday living in lowses neighbourhoods compared with living in middleses neighbourhoods at the age of 40 years was significantly associated with a higher risk of mi and chd before the age of 50 years lower risks of both mi and chd were seen in individuals living in highses neighbourhoods the results remained significant after adjustment for established individuallevel socioeconomic factors neighbourhood goods and services and hospital diagnoses of diabetes and hypertension prior to the age of 40 years comparisons with other studies an analysis of death certificates in texas revealed that individuals who had been living in areas with a higher median house value died of cardiovascular causes at an older age than those who had been living in areas with houses of lower value 15 compared with the most affluent individuals living in the most privileged neighbourhoods the increased cardiovascular mortality risk associated with living in the most disadvantaged neighbourhoods was stark it was the equivalent of being 10 years older at the baseline investigation among americans aged 4564 years old 16 higher cardiovascular mortality has also been reported in individuals above 65 years living in lowses neighbourhoods 17 yet to the best of our knowledge there are no previous studies investigating the role of neighbourhood ses on incident mi and chd in individuals below 50 years of age in the entire population of a country young individuals move around more than people in general but most individuals have had the chance to find a job and to settle in a neighbourhood by the age of 40 years therefore we build on the existing evidence by reporting striking differences in chd risk between younger adults living in lower and those from higher ses neighbourhoods possible explanation for our findings there are some possible explanations for our findings the association between neighbourhood ses and the risk of mi and chd may be explained by an increased prevalence of cardiovascular risk factors among lower socioeconomic groups and the lifestyles of the residents in the neighbourhoods in fact modifiable healthy lifestyle factors have been shown to be associated with established risk factors as well as incident cvd 18 healthier lifestyles have also been reported to be followed to a higher degree in individuals with high ses as compared with those with low ses 19 yet the individuals in the present study were 40 years old and diabetes and hypertension are not as common in people below 50 years of age as in older individuals 20 this suggests that these established risk factors do seem to be the main mediators of the higher chd risk in individuals residing in lowses neighbourhoods in addition the results remained significant when we adjusted for diagnoses of diabetes and hypertension registered in individuals discharged from hospitals prior to the age of 40 years individuals residing in a lowses neighbourhood may experience feelings of inferiority lower social status and selfdoubt 21 residents in these neighbourhoods may have less money to spend and may have been exposed to a higher degree of psychosocial 22 and financial stress 23 the physiological stress response to acute stress is known as allostasis and its longterm effects result in a buildup of risk factors known as the allostatic load 24 allostatic load scores mirror the price to pay for adaptations and those with high allostatic load scores have been shown to have lower selfrated health and a higher cardiovascular risk 25 certain immigrants have been shown to have higher rates of chd than swedishborn individuals 26 as many immigrants live in lowses neighbourhoods parts of our results could be explained by immigrant status yet we adjusted our models for immigrant status and the results remained significant suggesting that the higher proportion of immigrants in lowses neighbourhoods does not seem to explain the higher risk for mi and chd in fact the risk estimates when immigrants were analysed separately with adjustments for time since immigration were significant in men and had similar risk estimates in women there may be other factors affecting the health in neighbourhoods such as access to healthcare and pharmacies prescribed cardiovascular drugs have also been shown to be in agreement with guidelines to a higher degree in highses neighbourhoods than in lowses neighbourhoods 27 yet the results were still significant when we adjusted for neighbourhood goods and services including access to pharmacies and healthcare clinical implications our findings are particularly important to note as they are observed in a country with universal healthcare thus keeping constant an important potential confounder in the association between neighbourhood ses and chdrelated outcomes however despite the fact that sweden has a healthcare system approaching socialised medicine psychosocial factors have repeatedly been shown to have an effect on cardiovascular health 22 in a society with equal opportunities for health screening and intervention more effort should be directed towards identification of vulnerable groups such as those living in lowses neighbourhoods risk prediction models in highrisk groups for chd suggest that factors such as age sex smoking status glycaemic control cholesterol levels and blood pressure should be closely monitored 3 a recent study of longterm prognosis after coronary artery bypass grafting showed a considerable excess risk in patients with type 1 diabetes 28 neither individuallevel ses nor neighbourhood level ses was however included in those models alternative risk prediction models have been developed where qrisk2 included residing in neighbourhoods with different ses scores 2930 the performance of the qrisk score has in fact been shown to be better than the framingham model in identifying high risk for cvd we argue that neighbourhood and individuallevel ses should be given more attention in the clinical setting when physicians and other healthcare workers estimate the chd risk of patients limitations and strengths one of the limitations of this study was the lack of some data on established cardiovascular risk factors one of the major strengths of the present study was that we were able to include all individuals residing in sweden at their 40th birthday with data on their neighbourhood ses as well as data on individuallevel ses and follow them for cardiovascular events until the age of 50 years we believe that the internal validity is higher with this methodology than if all individuals below 50 years would have been included since many people live in different locations in their early years of adulthood the use of the total population register may be of particular importance since individuals in low resource settings have lower participation rates in surveys another strength is the patient register and the cause of death register in sweden which have been reviewed for validity and completeness 12 thus enabling a longterm evaluation of the outcomes without any significant loss to followup given the high internal validity of the study we believe that the study also has external validity and that the results may be generalisable for estimating the risks in highses and lowses neighbourhoods in other western countries conclusions the results of this study suggest a significantly increased risk of premature mi and chd in the younger middleaged swedish population who lived in neighbourhoods with low or middle ses compared with those individuals from highses neighbourhoods this relationship was independent of individuals education level marital status immigrant status and their region of residence in sweden the inclusion of neighbourhood ses in predictive models of chd may significantly improve the identification of individuals who are at high risk for premature chd and enable timely preventive treatment for individuals living in deprived neighbourhoods further efforts to reduce cardiovascular risk in younger adults living in deprived neighbourhoods are imperative key messages what is already known on this subject neighbourhood socioeconomic status has been shown to be an important risk factor for coronary heart disease independent of individuallevel ses among older individuals what might this study add after adjusting for individuallevel socioeconomic factors living in lowses neighbourhoods compared with living in middleses neighbourhoods at the age of 40 was significantly associated with 31 higher relative risk of myocardial infarction and chd before the age of 50 years how might this impact on clinical practice the inclusion of neighbourhood ses in predictive models of chd may significantly improve the identification of individuals who are at high risk for premature chd and enable timely preventive treatment for individuals living in deprived neighbourhoods further efforts to reduce cardiovascular risk among younger adults living in deprived neighbourhoods are imperative 69 marital status married 29

objectivethe incidence of myocardial infarction mi has decreased in general but not among younger middleaged adults we performed a cohort study of the association between neighbourhood socioeconomic status ses at the age of 40 and risk of mi before the age of 50 years methodsall individuals in sweden were included in the year of their 40th birthday if it occurred between 1998 and 2010 national registers were used to categorise neighbourhood ses into high middle and low and to retrieve information on incident mi and coronary heart disease chd cox regression models adjusted for marital status education level immigrant status and region of residence provided an estimate of the hrs and 95 cis for mi or chd resultsout of 587 933 men and 563 719 women incident mi occurred in 2877 048 men and 932 017 women and chd occurred in 4400 074 men and 1756 031 women during a mean followup of 55 years using individuals living in middleses neighbourhoods as referents living in highses neighbourhoods was associated with lower risk of mi in both sexes hr 95 ci men 072 064 to 082 women 066 053 to 081 living in lowses

introduction homelessness represents a longstanding problem with considerable individual and social costs homeless services coordinated at the community level struggle to keep up with demand for housing assistance and little evidence supports the accuracy of current decision making in the allocation of limited homeless services advances in machine learning and ai techniques have made it possible to apply learning algorithms to social problems ranging from police patrol to poaching many of these solutions have had success in mitigating the problem to which they were applied in this paper we test the feasibility of datadriven approaches to inform policies that guide homeless service delivery specifically we ask the question of whether one can use individual predictions of success for certain types of homeless services to improve outcomes across the population ethics and fairness since we are considering a problem of allocating scarce shared societal resources using algorithmic approaches it is important to foreground the discussion of ethical issues and fairness concerns the use of techniques from artificial intelligence and machine learning in different societal contexts have increasingly raised concerns regarding fairness accountability and transparency in a number of situations datadriven allocations have unintentionally introduced systematic biases that perpetuate inequities such as racial disparities in credit lending hotspot policing and crime sentencing the complexity involved in the development of decision algorithms has called into question the ability to design adequate protections against systematic misuses in response to these types of concerns the european union recently issued the general data protection regulation which imposes restrictions on how individual data can be used for algorithmic decision making in ways that significantly affect users the gdpr coincides with a broader argument for not just full transparency but rather human interpretability regarding how decisions are derived from algorithmic approaches to ensure adequate assessment of fairness however requirements for human interpretability could also diminish the potential of ai to solve societal problems algorithmic approaches generate novel solutions that may not correspond to human intuition requirements for full explainability of these complex processes limits the inherent value of applications to thorny social problems in a recent wired oped david weinberger raises a compelling example related to autonomous vehicles if they were able to lower the number of fatalities in us vehicle crashes by 90 would it really be worth losing that benefit because of the difficulty of explaining the remaining crashes certainly the answer to this partly depends on whether the remaining crashes disproportionately affect some portion of the population and perhaps other considerations weinberger goes on to argue that while the governance of ai applied to social problems is critical it can be achieved through existing processes for resolving policy issues the right approach is then to specify appropriate optimization goals arrived at through the social processes of policymaking which could be based on both efficiency and equity considerations resource allocation for social services a key difference in making resource allocation decisions on the basis of predictions in the social services setting when predictions are being made based on observational data is that the importance of causal modeling is magnified as opposed to the types of problems that kleinberg et al call prediction policy problems or for example using machine learning predictions of default to manage risk we need useful counterfactual estimates of the effects of different interventions in order to even define the resource allocation problem there has been significant recent progress in causal modeling from a machine learning perspective for our work we use bayesian additive regression trees which have the benefit of providing coherent probabilistic estimates of heterogeneous treatment effects thus it allows us to predict individual outcomes under counterfactual allocations while there is a long history of mechanism design research on assignment problems school allocation organ allocation refugee matching etc provide an excellent recent introduction to market design and much recent interest in the ai and broader computer science community in mechanism design for social good1 there has been limited prior work on homelessness specifically the most relevant study is that of azizi et al who consider allocation policies specifically for homeless youth they formulate a dynamic allocation problem between arriving homeless youth and two types of housing resources in order to fairly and efficiently allocate youth to these resources our focus moves beyond accurate screening to forecast response to multiple interventions using counterfactual approaches ours is one of the first studies to consider using machinelearning based estimates of counterfactual outcome probabilities to estimate the value of and thus inform allocation decisions for homeless services we present this work as a proofofconcept based on a real administrative dataset across the whole range of homeless populations in a metro area to address the following question by optimizing allocations based on predicted outcomes how much could we potentially improve outcomes and what would be the distributional effects of these improvements problem setup homelessness providers coordinate communitywide services that vary in level of intensity to meet household needs in the us services range from timelimited nonresidential supports to ongoing rental assistance with intensive case management at any given time the homeless system allocates many households to many interventions each subject to capacity constraints fundamentally homeless services aim to stabilize households and reduce future demand for assistance one commonly used metric of successful services tracks the number of households that use additional homeless services within two years of initial contact counts are generated from administrative data that record entries and exists across homeless services however routine capacity constraints make it challenging to measure success since those in need may not be able to receive services in this work we take advantage of unique local administrative records to assess whether households reenter homeless assistance within two years of initial contact regardless of whether they actually use the services the data available to us links homeless service records with requests for assistance through a regional homeless hotline we build and evaluate counterfactual models for whether a household would have reentered the homeless system if assigned to a different intervention and solve a capacitated assignment problem in order to minimize the number of households reentering the system within two years subject to capacity constraints on each intervention preview of results using administrative data on a weekly basis over the course of 166 weeks we find that the bart model is wellcalibrated it predicts in expectation 2227 of households would reenter the system and 2193 actually did in the optimized assignment we find the bart model predicts that only 1624 households would reenter the system thus there may be substantial benefits achievable from improving the combined predictionallocation mechanism however these benefits do not come without tradeoffs they are not even close to paretoimproving in fact as many households increase their probability of reentry according to the predictions as those that decrease their probability of reentry we also formulate and solve a constrained version of the allocation problem which guarantees that no household increases their probability of reentry by more than 5 percentage points in the new allocation in this case 3738 of households are predicted to reenter implications our work is intended as a proof of concept and a case study we bring data to bear on the question of how much ai techniques can improve social service provision with full awareness that the precise results presented may depend on specific modeling choices and the reliability of the counterfactual estimates we expect this work to contribute to the emerging dialogue on intervening based on machine learning predictions it is very important to consider fairness ethics and the longterm dynamics of systems that use these kinds of predictive modules at the same time the current state of practice in social services allocation is far from evidencebased therefore not engaging these questions with actual data and estimates could be leading to significant societal harm background and data homelessness represents a complex public health challenge for communities across the united states federal guidelines define homelessness as residence in unstable and nonpermanent accommodations this includes shelters places not meant for habitation as well as being at imminent risk for eviction counts estimate that more than 550000 people experienced homelessness in the united states on a single night in january 2016 and 14 million people used homeless services at some point during the year families with children under 18 years of age comprised 35 of the homeless population experiences of homelessness and associated turmoil carries life long implications as well as significant social costs the homeless system represents the primary communitywide response to housing crises funds allocated by congress on an annual basis support the delivery of five types of homeless assistance service types vary in intensity and relatedly availability the most intensive service permanent supportive housing provides longterm rental assistance plus comprehensive case management to address barriers to stability such as mental health and substance abuse treatment it is reserved for the highest risk households and consumes the greatest amount of financial resources transitional housing also offers comprehensive case management but only up to 24 months in congregate settings rapid rehousing allows up to 24 months of rental assistance without additional intensive case management at the end of two years households in transitional housing or rapid rehousing either move on their own or stepup to permanent supportive housing if available emergency shelters offer immediate accommodations for those with no other place to go and typically serve a large number of households for a brief period of time shelters are intended to stabilize households and divert highrisk families to the longerterm housing interventions finally homelessness prevention provides households at imminent risk for homelessness with shortterm and nonreoccurring assistance to mitigate housing crises local nonprofit provider networks determine the delivery of daytoday services within general structures determined by federal funding priorities despite substantial investments homeless rates remain stubbornly high in the united states an enormous challenge is that of matching service types to need while federal guidelines mandate that local agencies provide services based on risk assessments existing tools fail to discern high and low risk households beyond chance homeless service providers have limited evidence for adapting responses to household characteristics moreover there are no tools that assess the impact of service matches on overall system performance in reducing reentries 2algorithmic approaches offer substantial promise for addressing the optimization of homeless service delivery administrative records systematically track service usage and household characteristics over time and provide rich sources of information from which to glean insights into service improvements therefore potential exists to evaluate improvements in prediction that support decision making however as mentioned above the application of datadriven approaches for delivery of scarce resources to address homelessness requires careful consideration of fairness the feasible application of any algorithms must be transparent and assess unintended sources of bias data collection data for the project come from the homeless management information system of a major metropolitan area from 2007 through 2014 the hmis records all housing services provided to individuals and families seeking federally funded homelessness assistance local service providers enter information on requests and receipt of services in real time through a webbased platform in accordance with federal mandates for collection of universal elements a local nonprofit organization contracted with the homeless system hosts the platform and provides support including user training technical assistance and active quality control records provide information on the characteristics and services delivered to households in contact with the homeless system householdlevel characteristics includes an array of information on demographics housing risk assessments and eligibility determinations services include entry and exit dates from the five federally defined types of homeless assistance homelessness prevention emergency shelter rapid rehousing transitional housing and permanent supportive housing in addition the metropolitan area coordinates requests for assistance through a homeless hotline and householdlevel data record information on every call including dates and referral for services household identifiers allow linkages of information across time data sharing agreements with regional homeless systems allow access to deidentified records in accordance with the relevant institutional review board data cleaning and feature selection for this project we extract data provided by 75 different homeless agencies and link participants across programs by a unique anonymous identification number we then aggregate data by household using a unique household identification number this results in a dataset of households containing household characteristics available upon entry into the system as well as information on all entries and exits from different homeless services permanent supportive housing is meant as an intervention that households transition into after a certain period of time or the conclusion of a particular intervention and is meant for those who need continuing support because of the nature of this intervention and the fact that we focus on first entries into the homeless system we exclude permanent supportive housing from our analyses the primary outcome is reentry into the homeless system operationally reentry is defined as requesting services within two years of exit from the system regardless of whether services were actually received this ensures that we capture further need and not just availability of services when transitions between services occur on the same day we assume that they represent a continuation of homeless services we consider households to have exited from the system when the time between leaving one service and entering another exceeds one day our analyses include households who entered the homeless system after the start of 2007 and exited before the end of 2012 to provide a minimum twoyear followup for all households since the data captures homeless services across time it contains both timeinvariant as well as timevariant features we select values of timevariant features that are collected at the time of first entry into the homeless system and have adequate amounts of available data for use in our model most of the variables we selected were categorical and missing values are treated as a separate category in these cases data characteristics the dataset includes records on 7474 households of these 3216 reentered the homeless system within two years of exiting table 1 shows the number of households assigned to each service type as well as the percentage reentries within 2 years for each intervention of the 3216 who reentered 1522 were placed in a subsequent service while 1694 called the hotline for assistance but by the end of the two year period had not been placed in another service a single feature vector consists of covariate data for headofhousehold spouse and children as well as which service type the household was assigned to the target variable or label is a binary indicator of whether or not they reentered the homeless system within 2 years of exiting table 2 shows a summary and examples of the features included analyzing interventions the application requires a method that can handle the challenges of counterfactual inference using observational data while simultaneously providing a wellgrounded probabilistic model bayesian nonparametric modeling for causal inference has a number of advantages that fit this application these models provide robust estimates of treatment effects using observational data like administrative service records they can handle a large number of features or predictors as well as complex data that include interactions and nonlinearities seen in studies of housing assistance in child welfare we use bart an ensemble model that outperforms propensity score and nearest neighbor matching algorithms for causal inference on observational data especially when the data are complex bart can also explicitly address heterogeneous response to interventions based on empirically identified features in the data generating individual treatment effect estimates in addition to populationlevel ones building the model bart models the data by approximating f e as a sum of binary regression trees the sumoftrees model includes trees of different sizes and allows bart to incorporate both additive and interaction effects of various orders bart uses a regularization prior to restrain the effect of each tree and then uses a bayesian backfitting mcmc algorithm to draw samples from the posterior distribution at the start of the mcmc draws a chain of singlenode trees is instantiated during each iteration each tree can increase or decrease its number of nodes or swap decision rules between a parent node and a child node then bart computes a new sample from the approximated posterior distribution f as a sum of the results from the current set of trees these posterior samples consist of 1000 postburnin samples for each observation using bart to model the data produces a set of posterior draws for each household in the dataset allowing populationwide as well as householdspecific inference model fitting and counterfactual inference were done using the r package bayestree written by the models creators population treatment effects the key decision variable is the choice of intervention to which a household should be allocated for the larger enterprise proposed in this work to make sense it is important that different interventions actually have different effects while table 1 shows apparent differences in the probability of reentry based on intervention these differences could be due to unobserved variables or selection bias because of the nonrandom provision of services therefore we start by systematically investigating the differential effects of these housing interventions on the probability of reentry into homeless services within two years we compare service types by doing pairwise inference we select data for each pair and build a bart model based on this data we use bart to approximate the posterior distribution of reentry based on this model for the factual service type as well as the counterfactual then we take the mean and 25 and 975 quantiles of the difference between counterfactual samples and factual samples in order to find treatment effects and 95 estimated credible intervals for service type we do this for all pairs of service types as well as for homelessness prevention compared to any other service type pairwise differences show that populationwide treatment effects for emergency shelter transitional housing and rapid rehousing are not largely different from one another the only pairs for which there seem to be meaningful treatment differences are those that included homelessness prevention on average those assigned to prevention see a 1155 percentage point decrease in probability of reentering the homeless system compared to having been assigned to any other service with a 95 estimated credible interval of 8171367 optimal allocation using estimated personalized treatment effects in order to frame the optimal allocation problem we need two main sets of variables estimated from the data first are the actual predictions of probability of reentry for households given they are placed in each of the possible interventions for this we use outofsample bart predictions second are the capacities of the different interventionsthat is the number of beds available at a given time in order to estimate these we aggregate data on a weekly basis and match the number of entering households into the interventions to the capacities of those interventions in that week one week is granular enough to give some flexibility to the optimizer while also not leading to waits that are outside the tolerance of the system we note here that we solve the problem in a static manner every week although there could of course be interesting dynamic matching issues at play the optimization problem let x ij be a binary variable representing whether or not household i is placed in intervention j then the integer programming problem is given by min xij ∑ i ∑ j p ij x ij subject to ∑ j x ij 1 ∀i ∑ i x ij ≤ c j ∀j where p ij is the probability of household i reentering if they are placed in intervention j and c j is the capacity of intervention j we use this ip framework and gurobi optimization software to find an optimal allocation for households who entered the system during each week 3 only households who 3 this is essentially a capacitated version of the assignment entered the homeless system between october 2009 through december 2012 were included in the optimization resulting in 166 separate weeks optimized over the 166 weeks 2193 out of 5095 households actually reentered the homeless system using bart predictions to estimate how many households would reenter in expectation produces an estimate of 2227 households suggesting that the predicted reentry probabilities given by bart are reliable using these predicted probabilities to find an optimal allocation predicted reentries reduce to 1624 households thus the optimal allocation framework reduces the predicted number of reentries into the homeless system by 2708 over this period a truly substantial potential improvement in outcomes fairness considerations an immediate question is whether the optimal allocation is capturing some inherent inefficiency in the allocation system and is therefore paretoimproving or at least improving allocations for a substantial portion of the population this turns out to not be the case in the optimal allocation 1690 individual households are allocated to a service in which they have a lower probability of reentry than the service in which they actually participated another 1743 are allocated to the same service they were originally assigned importantly 1662 households are allocated to a service in which they have a higher probability of reentry therefore the optimal number of expected reentries is achieved by in effect hurting as many households as it helps in the original allocation at the same time the benefits to those who are helped are so strong that they outweigh the costs to those households who are hurt in an additive welfare model figure 1 quantifies this by showing problem which can with a little tweaking be reformulated as a weighted bmatching problem known to admit a polynomial time solution in practice the optimization is extremely fast in gurobi and time requirements are dominated by running bart also the optimization here leads directly to the formulation in the next section that adds additional complex constraints to the problem the distribution of changes in the probability of reentry between the two allocations differences in probability of reentry between the original allocation and the optimal allocation to further explore differences between those who benefit from the optimal allocation and those who are predicted to do worse we used a random forest to predict whether a household will have a higher or lower probability of reentry after the optimal allocation using all original features and ignoring service type we then were able to get measures of variable importance from the random forest model figure 2 shows the mean decrease in accuracy measure for the 30 most influential features this analysis shows that the two most influential variables for deciding which households will have a lower probability of reentry and which will have a higher probability are prior residence and housing status at entry table 3 shows summary statistics for a few of the most influential features for the group who improved the group who was harmed and the group who did not change we used students ttests for difference in means to assess whether values of calls before entry wait before entry monthly income and age of head of household for the group who improved and the group who was harmed were significantly different we found that all differences were significant with pvalues less than 0002 perhaps the most striking fact to emerge from this analysis is that the optimal allocation seems to help those who stand out as being more in need households with lower monthly incomes longer waits and fewer calls to the hotline before being placed and those who are have more serious substance abuse problems are more likely to be placed in interventions that are better for them in expectation this suggests an ability to improve upon the allocation rules currently used by the homeless system one possible explanation is that in the current system it seems inappropriate to assign people who are in more need to homelessness prevention however as figure 2 plot of the mean decrease in accuracy of features for predicting whether the optimal allocation will increase or decrease a households probability of reentry our results suggest homelessness prevention is more effective on average than any other service constraining increased probability of reentry it is possible that the inefficiency of the original allocation is in part due to humans making decisions in the interests of equity one way to potentially deal with fairness concerns like these is to make them explicit in the optimization as an example we consider what happens if we add a constraint that prevents any household from suffering too high a predicted cost from the change in allocation ∑ j p ij x ij ≤ ∑ j p ij y ij 005 ∀i where each y ij is a binary variable representing whether or not household i was originally placed in intervention j this constraint keeps households from being allocated to a service in which their predicted probability of reentry is more than 5 percentage points higher than that of the service they participated in originally when we include this constraint the solution to the optimization problem yields an allocation with a predicted 1904 households reentering the system within two years this is obviously higher than the optimized allocation without the constraint but still a 1466 decrease compared to the predicted reentry number for the original allocation looking again at individual households 948 households are allocated into a service where they had a lower probability of reentry 3175 are allocated into the service they were originally assigned to and 972 are allocated into a service in which they had a higher probability of reentry because of the added constraint no households suffer a penalty of more than 5 pp in table 3 summary statistics for the most influential features for determining which households will benefit from the optimal allocation differences in probability of reentry between the original allocation and the optimal allocation the new allocation in fact figure 3 shows that the majority that do worse suffer very small penalties discussion this paper tests the feasibility of using datadriven counterfactual approaches to inform policies that guide homeless service provision we analyze the potential for different allocation mechanisms to improve outcomes using counterfactual estimates of probability of reentry into the system we estimate that optimal assignments done on a weekly basis could reduce the number of reentries into the system significantly however a significant number of households are also hurt by the changed allocation thus datadriven benefits for the homeless system as a whole do not necessarily improve outcomes for all in an attempt to reduce the harmful effects to part of the population we impose an additional constraint to prevent households from suffering too much of an increase in the probability of reentry satisfying a notion of approximate fairness this still reduces the number of reentries into the system when compared to the actual allocation but including the constraint reduces the overall benefits from optimizing the assignment of households to interventions it is critical that fairness and justice considerations be thoroughly analyzed and addressed before algorithmic allocations are implemented one potential solution is allowing workers to override certain allocation decisions this idea has previously been adopted as part of a screening instrument used in new york city shinn and colleagues also mention that analysis of the reasons behind these overrides can help to inform future models of this type the addition of potential override reasons to an allocation model could help to increase fairness tune future versions of the model as well as make the transition to an allocation program smoother by allowing homeless service workers to maintain control over allocations the findings must be considered in context of study limitations the observational nature of the data makes it difficult to rule out all potential confounding variables that we were not aware of or to which we did not have access however the dataset included all variables measured consistently by the hmis for which there was enough available data avenues for future work include further analyzing traits of households who were reallocated to services in which they have a higher or lower probability of reentry it is very important to make sure that allocation systems such as this are not disproportionately harming specific groups additionally it would be interesting to look at which new allocations result in lower or higher probabilities of reentry for example are more people who end up with higher probabilities of reentry being allocated to emergency shelters rather than homelessness prevention answering questions like this will help us learn how to decrease the number of households harmed by this type of service allocation

modern statistical and machine learning methods are increasingly capable of modeling individual or personalized treatment effects these predictions could be used to allocate different interventions across populations based on individual characteristics in many domains like social services the availability of different possible interventions can be severely resource limited this paper considers possible improvements to the allocation of such services in the context of homelessness service provision in a major metropolitan area using data from the homeless system we use a counterfactual approach to show potential for substantial benefits in terms of reducing the number of families who experience repeat episodes of homelessness by choosing optimal allocations based on predicted outcomes to a fixed number of beds in different types of homelessness service facilities such changes in the allocation mechanism would not be without tradeoffs however a significant fraction of households are predicted to have a higher probability of reentry in the optimal allocation than in the original one we discuss the efficiency equity and fairness issues that arise and consider potential implications for policy

the most complicated machines are made only with words as if echoing lacan suchman points to rhetorical leaps that conjure into existence an imaginative landscape increasingly populated by socially intelligent artefacts … things that both think and feel like you and me a peculiar enclave of that imaginative landscape is formed when socially interactive robots are talked about in science and technology studies implicitly if not explicitly the issue of robot agency unfolds in dialogue with actornetwork theory its rejection of the subjectobject dichotomy and concern to liberate artefacts from the passivity that this dichotomy imposes on them in contradistinction the engineering field of social robotics could be described as dedicated to building machines that are liberated from passivity by design its discourse constructs entities that will step out of the lab as our ontological equals having minds of their own the rhetoric sometimes calls for redefining the fields goal in terms of the creation of an artificial person while defining person with language that is free of speciesism and implores us to regard social robots as beings worthy of respect … and expect that they hold us so in regard there is a tension between the idea of robots that are like us and construing all nonhumans as actors this tension is not a problem if we accept multiple ontologies but it gives the interface between sts and the engineering field of humanrobot interaction unique contours intellectual problems traverse disciplinary discourses one cluster of issues addresses the speculative question of whether smart artefacts could ever possess the kind of competences associated with human agency benchmarks for attaining this status might be formulated differently from the standpoint of engineering and cognitive science as opposed to sociology the other cluster whilst engaging with the same general question gravitates towards critical expositions of prevailing assumptions about agency and sociality as revealed in debates about artificial intelligence there are also tensions due to differences between what roboticists and social scientists consider as important to know on the one side besides technical issues of robot design and the scientific problems associated with those ethical concerns and sociopolitical interests may invite impassioned justifications of the industry on the sts side there is the ethnographers commitment to analysing impartially robotrelated activities in the given setting the scientific problems are constructed in terms of how best to describe and understand the role of the technological object in given settingsincluding descriptions of how behaviour patterns and norms unfold through bodyscaled interactions with robots alač introduces the topic thus what kinds of objects and things are we now engaging with social robots … make these questions even more challenging as their digital and physical materiality is orchestrated to produce effects of sociality and agency in a footnote to their commentary on current trends in sts woolgar and lezaun point to a dialectical tension between the impetus to probe ontological matters through developing a new mode of investigation and fixing particular configurations of reality presented in moves towards the production of new systematics as woolgar and lezaun put it alač could be seen as harnessing this tension she empirically probes the ontological issue of how a robot acquires its social character and simultaneously seeks to fix the particular configuration of reality that she develops through a concept of bodies in interaction her work in general represents the fields long tradition of research into the materialization of technoscientific entities and attention to embodied practices and practices of embodiment the bodiesininteraction thesis parallels suchmans contention that agency is best understood as enacted in subtle reconfigurations of a network of humans and artefacts the emphasis on bodiesininteraction resonates with a contemporary trend in sts the new materialism … the enduring relevance of the study of material culture the rise of thing studies and the spread of actornetwork theory in the following i draw upon some of alačs work taken mostly from alač et al in which she analyses interactions with robots in a preschool following a longitudinal studysocalled the rubi projectset up by tanaka and movellan my critical angle could be presented as deconstruction à la derrida what are the significant gaps the meaningful absences in discourses surrounding social robots significantly understated in sts is an account of the psychological complexity of human action including activities into which robots are semiotically assimilated as social agents højgaard and søndergaard make a similar comment they favourably discuss mosers theorywhich posits bodies subjectivities and abilities as effects of material practices and relationsbut reflect that when it comes to defining subjectivity moser doesnt seem to transgress the realm of everydaydiscursive understandings of subjectivity as a phenomenon i enter the stshri crossroads from a perspective that understands subjectivity as profoundly dialogical the dialogic nature of consciousness the dialogic nature of human life itself the single adequate form for verbally expressing authentic human existence is the openended dialogue bakhtins dialogism imported into social psychology and psychotherapy has enabled various reconceptualizations of social cognition subjectivity and selfhood marková defines dialogicality as the mental capacity to conceive social reality create it and communicate about it in terms of iother alterity she concludes dialogicality implies … responsiveness and responsibility it means taking a personal stance and being recognized by others as taking a stance similarly drawing on bakhtin in developing his own concept of the dialogical self charles taylor has averred that as human beings we exist inescapably in a space of ethical questions the dialogical self theory articulated by psychotherapist hermans and associates since the early 1990s describes the self as constituted of multiple ipositions in constant flux of dialogical relations to each other and to external voices for the present purposes suffice it to have a general notion of a dialogical space between people definable as a liminal state of betweenness wherein meaning is coconstructed and the qualification that r obots have not yet entered this liminal space except in human imagination the premise underlying this article is that robots cannot become authentic social agents unless they possess dialogicality however speculations about conditions under which future artificial intelligences might become dialogical selves is not my concern here the phenomenon of interest here is the presentday discourse about social robots the dialogical dimension is seldom realized as an issue for theorizing in both the hri and sts discourses and yet it is often implied in semiotic slippages whereby robots are talked about as if they were persons the next section notes some such instances in the context of hri and later sections explore the issue in the context of sts the penultimate section turns to body with particular reference to gibsonian affordances theory so as to identify the level of analysis at which dialogicality enters social interactions the hri context humanrobot interactions have been investigated systematically since at least the 1990s by the mid2000s this research track had increased in size and scope to become recognized as a specialist field in its own right it encompasses the whole of robotics since interactions between humans and robots underpin any use of robots even autonomous service and industrial robots are used by humans directly or indirectly social robots feature minimally in goodrich and schultzs agendasetting reviewmentioned in a single sentence as a subset of assistive robotic systems wheelchairs mobile robots with manipulators animallike robots and humanoids the first annual conference on hri took place in march 2006 in salt lake city usa successive hri conferences show a progressive widening of what is perceived to be within the remit of hri by 2010 the fifth hri conference in osaka japan was themed grand technical and social challenges and centred on addressing issues in anticipation of a future in which r obots may become our coworkers in factories and offices or maids in our homes they may become our friends the organizers of the eighth annual conference which took place in tokyo in march 2013 invited papers under themes of distinctively sociological flavours alongside the staple diet of engineeringfocused themes as they put it robotic solutions are increasingly applied to real world problems … these societal problems require a holistic approach to the design and development of robots that meet human needs address technical challenges and foster acceptance in everyday settings however engineers recognition of social and societal issues often serves as an invitation for technological fixes three years after the inaugural hri conference diocaretz and herik reflected that what so far did not enter the agenda and curricula is the personal and intimate relational dimension between a human and a robot they give the example of assistive robots in individualized healthcare since a robotpatient relationship requires facetoface interaction it is important to know what psychophysical and neurological mechanisms are activated in the human body so as to create a perception and experience of presence in addition the personal relationship involves inherent trust in order to build love and friendship including emotional attachment whilst they underline the epistemological necessity of knowing what activates affective reactions in human bodies the reference to inherent trust and to building love and friendship sets in motion dynamics of discourse whereby the loved and trusted robot is extricated from the material domain and is installed in the social the talkedabout robot ceases to belong to the category of machines we trust to function reliably and the category of objects we love personal things to which we are sentimentally attached instead it is talked about as we ordinarily talk about someone we love and trust and who may love and trust us in return the robot as an object formed in discourse is thus imagined into a dialogical space goodrich and schultz articulate a concept of dynamic interaction as the hri fields conceptual cornerstonea concept that places the emphasis on shaping the types of interactions that can and will emerge as humans and robots interact and that they pitch in opposition to the traditional conception of pure teleoperation or supervisory control their notion of a dynamic interaction directs attention to interactional patterns that evolve in a selfregulatory way the operator becomes more skilful and the robotic system too learns and adapts to its user the actions of both operator and machine flow together in synergy to effect and perfect the performance of the task goodrich and schultz define interaction as the process of working together to accomplish a goal but working together in this context does not mean a coconstruction of meaning and a sharing of goals as human coworkers might do goodrich and schultz highlight cases of humans and robots performing tasks that are external to both the dynamic interaction is prerequisite to improving the efficient performance of the task in social robotics however the focus is on interactions that are themselves the task being performed the assistive or companion robot does something for the human with whom it interacts this is closer to the relationships between service providers and their clients tutors and their students or pets and their owners than to the relationships between machine operators and the machines they operate in this context a reference to working together imaginatively places these robots in social spaces populated with interlocutors and tacitly positions the robot as an interlocutor again implying dialogicality the pragmatic challenge in engineering is to design robots that have at least some human social characteristics and can engage people in interactions that feel natural a common strategy is to identify what humans typically do in facetoface interactions in order to define what robots should be able to do eg recognize the presence of humans by means of vision touch and sound perceive and express emotions and participate in conversations the rationale that extant scientific knowledge of the mechanisms of interpersonal interaction in humans can be harnessed towards designing machines that achieve similar effects cuts across biologically inspired and functional design approaches the former seek to create robots that internally mimic social cognitive capacities for instance apropos robots cog and kismet w e want to build … a robot capable of learning how to imitate facial expressions from simple imitative games played with a human using biologically inspired mechanisms in contrast designers opting for the functional approach do not necessarily need to understand how the mind really works since the objective is to create robots that outwardly give the impression of being intentional agents as duffy put it i f the fake is good enough we can effectively perceive that they robots do have intentionality consciousness and freewill his statement implies the emergence of a theme pertaining to ways in which robots could be inserted into an iyou system the theme becomes explicit in his collaboration with a sociologist defining the self in accordance with symbolic interactionism their narrative presents the ontological clarification of the self as epistemologically a necessary step before tackling the technical problem of how to put a self in a machine a decade earlier fong et al identified a gamut of issues to do with creating a goodenough fake requiring design decisions about physical appearance personality as expressed in behavioural traits and how to give the robot the skills necessary for ensuring optimal engagement of human interaction partners most of these remain central in robotics at the time of my writing in addition themes of robot personhoodmachines with selves and entitlement to humanlike rights have also entered this field shifts of emphasis intersect conflicting ideologies within hri herik et al describe two camps at loggerheads with each other hotly debating how to steer the technology a societydriven camp takes safety security and supervision as its measures and opines that the world is driven and run by social aspects the society dictates the governance in contrast a technologydriven camp measures progress by means of interaction intelligence and imagination maintains that the world is driven and run by technological developments and that robots are here for further enhancements and new applications it means no less than that technology dictates the governance herik et al predict that since technological acceleration is imminent we will cross the limits of human understanding into the area of robot understanding in his roadmap for roboethics veruggio forecasts that within the present century humanity will coexist with the first alien intelligence we have ever come into contact with robots thus alongside the pragmatic concerns of r d marketing applied ethics and legislation there unfolds a technologydriven metanarrative of a future in which human lives merge with smart technology at every level of human existence the semiotic robot that comes into being through the technologydriven discourse implicates qualitatively different moral questionsas well as challenges for conceptualizing humanrobot relationshipswhich take the field beyond engineering seeking to align social robotics with sociology meister equates it with a specialism concerned chiefly or solely with humanoid robot companions hence different from both service robotics and hri arguably these categorical boundaries are not only difficult to maintain but also are obscure in the engineering literature within which the designation social is applied to a wide range of robots including biologically inspired designs modelled on insects dautenhahn identifies a variety of terms applied to robotssocially evocative socially situated sociable socially intelligent and socially interactivewith correspondingly diverse concepts for instance whereas socially evocative robots are defined by the responses they elicit in humans socially interactive robots possess skills to interact and communicate guided by an appropriate robot control andor cognitive architecture a robot can be socially interactive by means of teleoperation but to make it socially intelligent requires inbuilt architecture emulating the primate brain in general the machines that are most commonly talked about as social are definable as physically embodied intelligent systems that enter social spaces in community and domestic settings this definition excludes disembodied ais or bots such as automated response systems and search engines specifying social spaces avoids merely listing settings in which robots could be placed and prompts taking peoples experiences of the robot as the salient criterion for instance a robot nurse might enter patients social spaces whereas a robot surgeon or a robot janitor in the same hospital wont strictly speaking the above definition excludes robots designed as laboursaving appliances but researchers investigating the introduction of robot vacuum cleaners into american households found that participants came to regard the robot as a social entityascribing lifelike qualities to it and giving it a name gender and personalityand concluded that even a robot vacuum cleaner can mediate and enhance interpersonal relationships people often anthropomorphize their cars computers and other objects nonetheless it seems a peculiarity of talking about robots that the machine leaps out of the material environment and into the social pinpointing robot sociality among several open questions in robotics that fong et al identify is what are the minimal criteria for a robot to be social it remains open in 2017 there is a gradient or are degrees of sociality as well as qualitatively different ways of approaching its conceptualization kahn ishiguro et al differentiate ontological and psychological criteria the strong ontological claim is that future humanoids will actually become human and the weak claim is that humanoids will remain fully artificial despite appearing to be human psychological claims focus on what people attribute to fully humanlike humanoids the strong psychological claim is that people will regard the humanoid as human the weak claim is that people will continue to regard it as a machine cutting across the kinds of claims identified by kahn and his coauthors there are phenomenological criteria to do with the extent to which people experience the interaction with a robot as an interaction with a sentient being an early definition of social robots originally formulated in 1999 by dautenhahn highlights a functional similarity with human and animal individuals within a group social robots are embodied agents … able to recognize each other and engage in social interactions they possess histories and they explicitly communicate with and learn from each other this posits sociality as a trait or a set of competences that certain organisms possess and that can be built into machines since the mid1990s dautenhahn has drawn upon the social intelligence hypothesis in biology which posits that complex cognition and enlarged executive brains evolved in humans and other animals in response to challenges associated with social complexity she contends that a robots social skills ought to form an important part of its cognitive skills and the degree to which it exhibits intelligence thus challenging a prevalent notion that social skills are merely a necessary addon for improving its appeal to users this nevertheless posits sociality as biologically hardwired in species that evolved that way and therefore as something that can be potentially reverseengineered whether or not her recommendation is technologically feasible and whether the social intelligence hypothesis is tenable in biology it seems indisputable that our capacities for sociality have an evolutionary origin and biological basis but having a capacity for engaging in social interactions does not mean that everything we do is social there remains the issue of defining sociality during the past decade the widening applications of robots in everyday settings have brought issues concerning longterm humanrobot relationships to the forean exigency evident in a spate of publications that could be viewed as a nascent relational turn or what šabanović and chang term a social turn in robotics it is expressed in research interest in users subjective experiences social and cultural factors affecting peoples perceptions and societal concerns about robots a subtle paradigm shift can be detected along with these widening interests since the mid2000s some roboticists have begun to assert that a robot becomes social by virtue of how people regard it for instance a social robot is a robot plus a social interface a social interface is a metaphor which includes all social attributes by which an observer judges the robot as a social interaction partner redefining the robots social character as contingent on peoples judgments signals a shift away from construing sociality as a trait that enables individuals to interact in a social manner and towards construing it as an emergent property of the interaction itself consequently the question about the minimal criteria for a robot to be social raises a question about the minimal conditions for a social interaction could a robot be classed as a social agent if it elicits a social reaction in people recalling her visit to rodney brooks lab in mit turkle describes her response to the robot cog as visceral cog had a face it made eye contact and it followed my movements … i had to fight my instinct to react to him as a person her point is that humans are hardwired to respond to social cues and robots can be designed so as to create a powerful illusion however this illusion is not the same as being involved in an actual interaction could an interactive robot in teleoperation scenarios be classed as social having placed an android replica of roboticist hiroshi ishiguro in an austrian café and documented visitors interactions with it straub found that minimal signs of reactiveness spurred visitors to behave differently than when the android was idling when it was teleoperated so as to be fully interactive visitors appeared to ascribe a distinct identity to the robot itself and forget about the teleoperating person as the source of the interactive performances it might seem selfdefeating to investigate dynamics of social interactions involving humans and robots when the robot is in fact another human what is known as wizard of oz technique is defensible in the context of hri observing how people respond to robots that seemingly display behaviours more sophisticated than what current technology allows could help robot designers to identify directions for building machines that may eventually achieve that degree of sophistication but if the social scientific aim is to analyse how the specific technological object has entered the given social space using the wizard of oz technique raises the question of exactly what we are seeing one way to look at these cases is in terms of simultaneous simulation and dissimulation to dissimulate is to pretend not to have what one has to simulate is to feign to have what one doesnt have applied to stage magic dissimulation means that effects are achieved by an apparatus that prevents spectators from knowing the methods and mechanisms producing the effect smith points to an overlap of the concept with suchmans reference to the erasure of human labours around technological performances and citing alač et al draws a comparison with recent productions of computerized life forms especially those of social robotics in both stage magic and social robotics the experiential effect is produced by the combination of simulation and dissimulation creating an effect known by all to be contrived while simultaneously erasing signs of its contrivance in machinery and method yet whilst positing the semiotic as inseparable from the materiality of artefacts and apparatus suchman draws attention also to rhetorical modes of erasure of human labours and nonhuman alignments whereby an artefact is brought into existence as an autonomous agent alač et al reflecting that they have often heard remarks that compare social roboticists with magiciansremarks insinuating that the robots performance is controlled by the roboticistssum up their own paper as showing instead that the flow of the interaction … is a process of participation and coconstruction since in their study childrens spontaneous actions played a significant role in establishing the social character of robots installed in the classroom this argument may parallel some variant of psychological claims but likely will fail to persuade proponents of ontological claims could a robot be classed as social only if it autonomously participates in meaningful exchanges with people arguments for and against insisting on this condition often cite the eliza effect referring to evidence that people interacted with the computer programme eliza as if it were a person the question of whether an ai could ever be accepted as another human is often articulated in terms of whether the ai will pass the turing test and deceive people about its artificial nature this raises philosophical issues concerning the extent to which the artificial system would require bodily engagement with the world in order to acquire the kind of interactional expertise that would allow it to pass as human the possibility of deception may be ruled out when people actually see the robot but there remains the question of whether being fully autonomous would make the robot truly social dominey and warneken sought to simulate how humans coordinate actions with each other in a study that dispensed with a humanoid appearance they extrapolated a theory of shared intentionality championed by tomasello according to which our species has evolved a unique capacity to share goals and intentions and our minds learn to process social information through forming dialogic cognitive representations the cooperator engaged with a human partner in a gamelike activity that involved taking turns in placing moveable pieces of a wooden puzzle in response to the partners spoken commands since the robot performed the task as the human did dominey and warneken have presented the study as proof that the hypothesized mental process can be translated into algorithms and be put in a machine not everyone is impressed thompson et al suffice it to quote gh meads definition of the social act a dynamic whole … something going onno part of which can be considered or understood by itselfa complex organic process implied by each individual stimulus and response in it hri studies often analyse humanrobot dyads as if in a social vacuum but increasingly there is also attention to how persons judgments of robots are influenced by others interactions with the robots lab experiments indicate that peoples appraisal of an android is likely to be influenced by seeing another person making eye contact with it since robots are becoming commercially available hri researchers too are leaving the labor take the lab to the wildand opportunities arise to observe the dynamics of multiparty interactions studies investigating how paro was used in elderly care homes found that the presence of the robot encouraged residents to communicate with each other on which basis the researchers surmised that the robots presence strengthened the residents interpersonal ties however when observational data are quantified so as to demonstrate behavioural probabilities the social act in meads sense vanishes from sight in contrast with the above alačs bodies in interaction approach echoes meads holistic definition of the social act apropos my title question she provides the compelling answer that any conception of the robot as an interlocutor must take into account the dynamics of interaction and further asserts t he robots social character extends beyond its physical body to include multimodal interaction within everyday routines the robots social character thus includes its positioning in the space and the arrangement of other actors around it as well as its interlocutors talk prosody gestures visual orientation and facial expressions this is diametrically opposed to the premise underpinning an assertion made elsewhere by her coauthors an electronic circuit with a few switches resistors and capacitors can be used to provide an index of what appears to be an abstract concept the ongoing quality of social interaction to mead the ongoing quality of the social act is irreducible to peoples reciprocal behaviours it is the difference between looking at someone and making eye contact or between an actual conversationan observable event that can be recorded and analysedand the dialogical space that opens up between people in conversation which is unobservable and unanalysable this quintessential phenomenological quality of a social act its dialogicality cannot be translated into algorithms and built into a few switches etc that may enable a robot to take turns in a conversation we may query the extent to which roboticists objectives are served by the insinuation that a robots social character does not reside in its design meister points to tensions between the position articulated in alač et al and what engineers are trained to do tensions that render alačs claim counterintuitive in the context of hri my position is more sympathetic to alačs oeuvre meister calls for developing robot architecture on grounds that in alačs terms to be deemed social a robot needs to possess mental configurations such as frames and scripts so that it can for example identify intentions of others and execute actions alač argues that the internalist proposal makes it difficult if not impossible to see participants actions as sensible her own analyses of classroom interactions vividly demonstrate how a robot lacking the frames and scripts called for by meister nonetheless engages children and their teachers in meaningful interactions to alač this evidences the robots agential and social character to me those interactions reveal human dialogicality including the capacity to coconstruct makebelief with a roboteven when the robot is switched off as will be seen in the next section dialogical action in a giveandtake game with rubi rubi was a threefoot tall plump robot clad in bright yellow cloth with a head two arms and a touch screena design that proved to be pleasing and nonthreatening to young children it was developed for a longitudinal study carried out by the university of california san diegos machine perception laboratory in the mid2000s along with sonys qrio rubi was placed in the universitys early childhood education center for six months its teleoperated performances were achieved by means of an elaborate apparatus involving hardware software and human resources spread across at least two rooms publications and conference papers generated from the project indicate that it has yielded a wealth of information relevant for robot design alač et al present alačs argument through detailed analyses of two scenes and reflections on additional observations i have selected an episode in which rubi was deactivated since the dramatic goingson can illustrate not only the contingency of a robots social character on its assimilation into spatially organized human activities but also my point that such assimilation implicates a dialogical dimension that challenges a construal of robots as social agents the episode opens with the teacher and the principal investigator sitting on the floor facing each other and engaging two female toddlers who are standing next to them rubi switched off seems to have been forgotten behind the pis back the teacher tries to get the girls interested in plastic toast and pizza an older infant twoyearold greg enters the room silently approaching the group he observes their activity and glances at rubi reaching the teacher he tries to take the toy pizza she is holding the teacher asks him whether hed like to have it greg removes his hand and looks again at rubi the teacher gives the pizza to the pi greg grabs it from the pi and ignoring the teachers prompt to thank the pi moves towards rubi the pi leans over touches rubis hand and waves it greg offers the pizza to rubi and the pi says thank you in a highpitched voice for the rest of the session the pi continues to lend his body to the machine while greg and the two other toddlers place toys in the robots hand the dialogical action unfolding in this scene does not mean simply taking turns in a dialogue taylors sense denoting the constitution of the selfknowing subject the i as an articulate identity defined by its position in the space of dialogical action a twoyearold has yet to grow into this space of dialogical action adults scaffold the childs inculcation into it from the moment that greg tries to take the toy from the teacher she attempts to make him take ownership of the intentional states she imputes into his behaviour did you wanted i use the italicized term in sic it greg greg wanted it yeah he says nothing but nonetheless asserts his autonomy by removing his hand from the toy the teacher then attempts to draw him into a giveandtake game teacher ill give it to japapa rubi and then you ask papa rubi greg teacher say thank you greg pi oh he is going to give it to rubi greg g r g teacher you wanna give it to mama rubi when greg does that the teacher is the first one to say thank you the pi then chimes in with the highpitched thank you the adults thus collude in bringing the toddler into their game of saying thankyou greg is not completely silent but his vocalizations do not amount to intelligible speech without hearing the prosody and seeing the body language it is difficult to tell what exactly was going on there based on the transcript alone the scene could be read as a power play greg seizes an object in which the adults appear interested he seems interested in the robot the pi quickly follows his lead becoming a puppet masterperforming affiliation and simultaneously retaining power the teacher retains her position of power by continuing to articulate gregs intentions on his behalf rubi may be the centre of attention and activity but it has no say whatsoever in the dialogical dynamics of this social act the robot remains a voiceless thing alač asserts this act of turning an object into an agent is not a metaphoric process but an achievement that involves the materiality of the robots bodyininteraction through the coparticipation of the groups members the robot talks while its body moves it could be argued that the transformation was entirely metaphoric rubi talks and moves only in makebelieve even when activated the ghost in the machine is a human operator in the focal episode the groups coparticipation in the pretence did not make rubi a social beingsomeone with a voice any more than the toy greg had offered it became real pizza through the gesture nevertheless alač challenges us to consider who is talking who is waving the hand is the agent the pi or is it greg or the robot the scene in focus reveals a deepseated tension between the giveandtake activity which attributes the agency to single individuals and the extent to which the participants gestures talk and actions configure them as multiparty situated achievements arguably the deepseated tension exists only in academia it is manifested in perennial controversies and in scholars construal of a problem with folk psychology outside certain intellectual enclaves extending agency to a robot still goes against the grain to echo wittgensteins reflection apropos language games i believe that he is suffering do i also believe that he isnt an automaton it would go against the grain to use the word in both connexions in the language game played out through the text in focus it does not go against the grain to say that the robots attainment of social agency is grounded in the specificities of the preschool routine and to observe that when the pi moved rubis head and arm to receive the toy from greg the robot functions as an interlocutor in the historically shaped interactional dynamics of which it is part the added emphasis highlights rhetorical moves that disrupt the ordinary language game the word interlocutor means a speaker and yet rubi does not speak adults playing with toddlers frequently act as mouthpieces for dumb toys as the pi did with rubi on this occasion but the voice is the adults to speak of a robots attainment of social agency parallels the standpoint attributed to latour according to which our interaction with technological artefacts is … a reciprocal exchange between actors a common critique of ant is that it flattens and squeezes out any psychological complexity from its notion of agency similarly the endorsement of humannonhuman symmetry and positing social agency as an emergent property of a hybridization of human flesh plastic and wires what kind of agent is rubi we may start by eliminating what kind of agent rubi definitely wasnt it was unlike the androids conjured in rameys describes as a literal crossover the swapping of properties from human to nonhuman ramey is not merely saying that competences associated with human agency are potentially transferrable to androids he takes it for granted that future technology will deliver those machinesand this inevitability raises the ethical issues he points out in contrast latour draws a picture of presentday sociotechnical reality in which nonhumans are folded into the social world by virtue of regulating our everyday conduct he gives the example of the speed bump socalled sleeping policeman this nonhuman plays an active role in enforcing a speed injunction we are no longer justified in viewing the speed bump as mere object inert and incapable of action since its constitution of concrete paint and gravel contributes to the meaning of law enforcer elaborating upon the example latour notes that the shift is actorial the sleeping policeman … is not a policeman does not resemble one in the least in rameys thesis the shift is in the opposite direction androids resemble humans and therefore ought to be recognized as artificial persons the difference between these discourses thus lies in whether they prompt us to judge a robot as social on the basis of how closely it simulates a human actor or prompt us to consider its actorial efficacy an agent in this sense is something that has an effect rubi had an effect the robot was a unique fixture in the preschool classroom it invited interactions that would not have taken place otherwise thereby organizing the goingson in definite ways its effects on the people interacting with it could be described without anthropomorphic projections for instance in terms of kurt lewins concept of aufforderungscharakter objects are not neutral to the child but have an immediate psychological effect on its behaviour … these imperative environmental factswe shall call them valences determine the direction of the behaviour a lewinian construal might depict greg the pi and the teacher as operating upon their environment as if they are separate from it this view is quite different from the latourian one in which operating only takes place in networks of actors that cannot be separated the subjectobject dichotomy that latour attempts to disrupt could be regarded as a legacy of construing the person as a bounded unique more or less integrated motivational and cognitive universe a concept that is peculiar in the worlds cultures the peculiar concept posits the psychological interior as prerequisite for agency since human agency presupposes intentionality forethought selfregulation and selfreflectiveness with particular reference to ant sayes identifies several ways of construing nonhuman agents none of which implies intentional states in the artefact a step up from regarding artefacts as merely instrumental is to understand them as mediators understood thus nonhumans are not actors in the proper sense of the word but are seen as necessarily adding something to a chain of interactions by continually modifying relations between actors and therefore cannot be treated simply as substitutes for human actors nonhumans are both changed by their circulation and change the collective through their circulation they act and as a result demand new modes of action from other actors goodrich and schultzs aforementioned concept of dynamic interaction in hri can be placed here the role of nonhumans as mediators comes into sharper focus when we consider the synergy between human behaviour and the machines they operate for example cars demand new modes of action from people who wish to drive them although greg offers the pizza to the robot not to a peer or an adult he does not do anything that cannot be done with another person or indeed a traditional doll it is difficult to attribute gregs action to the fact that rubi was a technologically sophisticated artefact to be sure children would respond to a socially interactive robot differently than to an inanimate object a study comparing how 2½6 yearolds interacted with the robot dog aibo and a stuffed toy dog reports similar affectionate behaviour towards both objects but significant differences that reflected reactions to aibos reactiveness with aibo the children were more often apprehensive and attempted reciprocity with it and they mistreated the stuffed toy more often by age four most children make clear distinctions between prototypical living and nonliving kinds and tend to designate robots to the inanimate group yet research investigating childrens attributions of aliveness to robot pets with which they actually interact suggests the emergence of a new ontological category that disrupts current animateinanimate distinctions aibo was discontinued in 2006 but robot companions for children are increasingly pushed by the industry targeting busy parents who can afford the gadgets for instance in autumn 2016 avatar mind introduced humanoid ipal as a great companion robot for kids with its cute cartoon outlook fine craftwork latest natural language understanding technology and cloud apps it will be your childs best friend whether children growing up with robots might suffer psychological damage or benignly acquire a new ontology a robot companion would not become a significant other for the child unless the robots voice becomes differentiated in the childs experience from those of other persons with whom the child regularly interacts thus entering processes of the childs dialogical self presentday robotic products could affect child development in subtle ways for instance a litterbin that runs after children urging them to pick up their litter sounds like a good idea but enticing children to comply with a robot is not the same as teaching children to obey their parents such gadgets potentially reorganize power relations within the family and thus the space of dialogical action into which children are entered as selves in sayess classification the next step up from nonhumans as mediators posits nonhumans as members of moral and political associations he cites examples given by latour an annoying bleeping noise sounds when a drivers seatbelt is not on or the ignition does not work unless the seatbelt is worn the bleep and ignition control constitute a new type of moral or political actor whereby the very fabric of our moral and political associations has changed rubis membership in a moral or political association is less direct instead of changing the fabric of morality and politics within the classroom by making the children behave in a desirable manner this robot appears to be on standby for the teachers agenda as seen the teacher seized the opportunity to foster etiquette through the giveandtake game tanaka et al report that early on some children cried when robot qrio fell the researchers advised the teachers to tell the children not to worry since the robot couldnt be damaged but the teachers had another lesson in mind ignoring the roboticists advice they taught the children to be careful otherwise children could learn that it is acceptable to push each other down the teachers treated the robots as instrumental an aid to socializing tanaka subsequently explored this potential in his concept of a carereceiving robot further testing the concept tanaka and matsuzoe describe how 3yearold japanese children in an english class spontaneously acted as a teacher to nao when the teleoperated robot placed there as a classmate appeared to get vocabulary wrong tanaka attributed the robots careeliciting affordances to its design however the caring was spontaneously demonstrated by some of the children some of the time emotional attachment to robots need not reflect the artefacts capacity to reciprocate the case of us soldiers holding funerals for their broken drones machines that had helped to keep them alive demonstrates bonding with robots that are not designed for social interaction as one blogger commented apropos funerals for aibo in japan robot funerals reflect our humanity in such scenarios robots seem to hold affiliative powers in terms of the ways in which objects are not innocent but fraught with significance for the relations that they materialize put another way the robot has affiliative affordances for humans who have feelings towards it judging a robot by its affordances the human body that functions as the fulcrum of sociological analysis is produced as a whole object at the intersection of multiple semiotic systems the bodywithoutorgans which presents its smooth slippery opaque taut surface as a barrier an added twist in the present context is that the bodies in interaction may include entities that are literally without organs the humanoid robot is discursively produced in parallel to the human body as an aiwithoutalgorithms insofar as technical details of its computational platform are tangential for describing peoples behaviour attitudes and semiotic designations visàvis the robot this framing of the subject matter can be contrasted with the bodywithorgans and its analogous robotwithalgorithms in cognitive science and robotics macdorman articulates the scientific problem thus how can human bodiesand perhaps robot bodiesconstruct themselves into persons by attuning to patterns and norms in their social environment the cognitivescientific problematic inverses the sociological problematicnamely how do patterns and norms in the social environment construct human bodies into personsand its extension into sts in which context the how question invites descriptions of how artefacts alter social spaces james gibsons ecological approach to sensory perception concerns organismic bodies in interactions with their material environment during the 1960s and 1970s gibson eschewed mentalism and articulated his theory of information pickup in opposition to the information processing models that dominated cognitive science of the day his concept of affordances modifies lewins aforementioned concept of valences whereas valences can be positive or negative and change according to the perceivers momentary state affordances are action opportunities and constraints that inhere in invariant characteristics of an animal and its environment and are therefore neutral a critique emerged in the late 1980s among progibson psychologists who problematized issues that gibson hadnt such as cultural relativism and the role of language through its original and subsequent formulations the concept of affordances epitomizes a principle of reciprocity that some scholars regard as gibsons key insight the reciprocity of affordances is not reciprocal causality two interacting entities can have causal effects on each other but that is not the same as constitutive complementarity eg the distinguishable yet mutually supportive realities of car mechanics and driver behaviour such a potential complementarity exists even for ablebodied people who have not learned to drive after gibson we may posit a drivercar hybrid and investigate how this symbiotic entity negotiates a path of safe travel a view that could be taken as concurring with latours humannonhuman symmetry there have been some attempts to integrate gibsons ecological psychology with ant or postant frameworks but the difference between the two frameworks is germane here each framework has a blind spot with respect to something that the other framework brings to the fore imagine a road that is closed off by a barrier following latour we may comment that the barrier enforces access restrictions a no entry sign serves the same purpose with respect to drivers though less effectively and it wont stop pedestrians or animals from walking on a natural obstacle such as a fallen tree does not have the same sociological significance but it has the same psychophysical significance as does the barrier following gibson we observe that large sighted animals pick up the impassability of the barrier and tree alike it is a mistake to separate the natural from the artificial as if there were two environments artefacts have to be manufactured from natural substances today gibsons ideas inform also robotics clearly an autonomous roboteg a selfdriving carapproaching a road barrier or a fallen tree should be able to pick up the obstacles impassability the affordances of a robot for people are a different matter gibson understood the social realm in a profoundly biological sense to individuals other animals afford complex interactions such as sexual predatory nurturing fighting playing cooperating and communicating and what other persons afford comprises the whole realm of social significance for human beings to gibson the significance of the social realm is evident in the fact that people pay the closest attention to optic and acoustic information that discloses what others afford them for a robot to enter this realm of social significance would mean more than people paying close attention to sensory information about what it affords them they will care whether the robot likes or dislikes them feel they are being rude if they dont thank it be offended if it is rude to them and so forth in short the robot would be assimilated into a dialogical space a construal of social that is closer to social scientific uses of the word enters the postgibsonian critique in its attention to culturally specific affordances such as the eatingwith affordance of a fork and chopsticks costall as coined in jones indexical affordances pertain to the denotative properties of utterances gestures and images a concept that can apply also to artefacts we may say here that in alačs example the teacher instructs the children about the toys indexical affordancethe fact that it can be used to represent a pizza although it lacks the material affordances of edibility rubi facilitated the playful activity through its indexical affordance as a humanoid as seen the teacher also trains greg in making indexical commitments to his own intentions by articulating what she assumes he wants to do and inviting him to confirm thus bringing the child into consciousness of his self the teachers interpretations connote mental states in the child participants in the giveandtake game are positioned as a givertaker politeimpoliteactions which connote individual agency within human symbolic interactions such reasoning clearly moves away from the materiality of artefacts and their invariant affordances for human bodies the word affordances has become common parlance and detached from its gibsonian origin suchman speaks of the indexical affordances of machine speech and … the ways that subjects and objects together can perform interesting new effects without reference to the gibsonian theory her use of the phrase also differs from joness postgibsonian concept of indexical affordances although both denote the openendedness of language as structuring conversational interactions in the cited extract suchman comments on designing automated systems for openended conversations with people as a step towards remodelling the artificial interlocutor not the artefactsthat create affordances for dialogicality within this autopoietic chain of affordances a robot can be semiotically designated as having a social character conclusion the epigraph at the beginning of this article quotes a statement that lacan made in a 1954 seminar in which he urged his audience to read la mettries lhomme machine reading both lacan and la mettrie de vos attributes to lacan the realization that la mettrie was one of the first to understand that with the emergence of science we also see the emergence of the symbolic mathematized body with zero subjectivity this symbolic body epitomizes a paradox already present in la mettries thesis there is inevitably subjectivity in imagining oneself as a being without subjectivity the subjectivity paradox acquires a new twist in the discourse of ai and robotics which endorses the technical feasibility of artificial minds we dont have to imagine ourselves as being machines devoid of subjectivity we can imagine machines with subjective states locating social agency in the hybridization of human flesh plastic and wires performs a further twist that squeezes out the residual ghost hybridization is a process that produces a hybrid hence instead of imagining ourselves like machines devoid of subjectivity or alternatively imagining machines endowed with subjectivity we are cued to imagine ourselves as existing symbiotically within a multibodied cyborg hybrid and yet behind this posthuman parlance there is inevitably someone a person with a point of view who engages in dialogues that seek to eradicate the cartesian ghost the subjectivity paradox prevails dialogism hardly resolves the intractable mindbody problem but making a case for considering it apropos social robots may nudge the problem space in this context towards a reconceptualization of robot sociality arguably a robot will become truly social only if and when it autonomously and inescapably partakes in dialogical action irrespective of whether this criterion can serve as an achievable benchmark for nearfuture robotics its absence in the technologyoriented discourses is significant it reveals something about the intellectual and imaginal landscapes within which particular expectations about robots unfold social robotics could be construed as a technology that strives to convert qualities of interpersonal relationships into commodities that can be stored and then supplied on demand this statement loosely paraphrases heideggers description of modern technology as storing energy although the analogy is limited suffice it to cite his example of a plane on the runway we see the object but its purpose is not apparent it conceals itself as to what and how it is … it stands on the taxi strip only as standingreserve complex machinery which is not visible to onlookers prepares the plane to take off he talks of the way in which the actual reveals itself as standingreserve alač et al show that even an inanimate humanoid a deactivated rubi can reveal itself as standingreserve for sociality if and when people include it in their social activities however whereas the plane reveals its purpose by mechanically performing its function regardless of any observer rubi invited gregs action through its humanoid appearance and the history of its placement in the classroom when greg hands the toy to the robot bodilyscaled his action is lodged in a series of prior encounters with the robot and the rubi team given his previous experiences the child might well have expected rubi to become animated as if of its own accord though he wasnt put off by the fact that it was visibly manipulated by the pi in this instance the technologyinaction seems to have mattered less than did the human action that the artefact elicited in instances of interaction with autonomous robots the artefacts capacity for responsiveness and the kind of responses of which it is capable clearly do matter the appearance of such robots in everyday settings challenge the sociological imagination to consider not only whether robotising social spaces induces new ontologies but also to consider whether scholarly descriptions of these emerging sociomaterial collectives forget fundamental aspects of human personhood she urges a reimagining of humans as contingently divisible participants in sociomaterial collectives who live out their particular histories in uniquely inflected ways as opposed to the entrenched image of the monadic rational actor contemporary psychology has long jettisoned the contested image and replaced it with models similar to the reimagining called for by suchman such as hermanss dialogical self theory and other frameworks articulated since the 1980s nonetheless it could be argued that they do not attend enough to peoples situated embeddedness in sociomaterial collectives the converse could be said in the present context the dialogical tends to drop out of sight when the scholarly gaze is fixed on sociomaterial collectives whereas gibsons affordances and costalls canonical affordances alike refer to potentialities that are present in persons environments the affordances to which i want to draw attention are autopoietic selfcreating and bring into existence the dialogical space that we inhabit as selves the giveandtake with rubi indirectly provides a vivid illustration of how human actions can have affordances in their own right alač et al describe how the pi orients bodily to what the toddler is attending to as he follows the direction of gregs looking the pi extends his upper body to the left touches the robots hand and waves it in classic gibsonian terms rubi has a makemewave affordance by virtue of having a moveable hand this affordance exists for any ablebodied human whether or not individuals realize it with costall we may observe that rubi has a makebelieve affordance akin to the canonical affordances of dolls or puppets canonical affordances exist as potentialities within cultural scripts a further layer of affordances becomes apparent in the observation that the pis gesture builds upon gregs orientation to create a referent of joint attention the pis action of waving rubis handitself a response to gregs action of looking at rubifixes the robot as a referent of joint attention and creates a new affordance for action greg can now perform the action deemed desirable when the robot works properly he can give the toy to the robot in turn the toddlers act invites the pis thank you while rubi and the pizza are indispensable for the makebelieve it is the participants actions

jon e s r ay a a 2 0 1 7 w h a t m a k e s a r o b o t soci al s o ci al s t u di e s of s ci e n c e 4 7 4

introduction in the past twenty years several studies carried out by the european commission have pointed out that the presence of women in certain scientific fields is low and does not represent their academic background this situation has resulted in the creation of campaigns and in the development of policies in several european countries to try to reduce this gender gap accordingly many bibliometric studies have been conducted to try to determine the scientific production of women in different scientific fields as well as to try to detect possible gender biases other studies have focused for instance on the presence of women on the editorial boards of scientific journals this interest arises because the participation in such committees provides the opportunity to make relevant decisions that influence both the editorial processes and their policies in the case of prestigious journals this situation ends up creating an epistemic lobby that contributes to the impulse and development of certain disciplines thus acting as obvious referees when the articles that have been sent for review are placed on their specific field of research on the other hand members of the editorial board can promote journals by encouraging their peers to submit articles for publication this kind of editorial activity indicates achievement recognition and leadership within the academic community and also allows for the establishment of important scientific and professional collaboration networks hence it is worth to investigate whether women have been equally incorporated into the editorial boards of academic journals and if so to what extent our research focuses in spain a country that has introduced laws to reduce the gender gap in science for instance the 142011 law on technology and innovation states that gender balance in the composition of selection committees must be met in university appointments for permanent professorship positions also the abovementioned ministry has created a women in science unit that aims to ensure the gradual establishment of equality policies literature review the editorial boards of medical journals have been reviewed thoroughly twelve prestigious medical journals were analysed finding out that only 25 of them had a woman as its editor and that only 17 of these journals had women on their editorial boards moreover the editorial boards of 16 biomedical high impact journals were analysed during a period of thirty five years to determine their number of members as well as their gender it was found that during the analysed period there was an increase in the presence of women on editorial boards although this presence did not reach 25 as there is a shift from an average of 1 in 1970 to an average of 21 in 2005 in another study on the proportion of women on the editorial boards of topranked medical journals of wosjcr categories 60 journals were analysed and it was found that out of 4112 members of these editorial boards only 155 were women these results are very similar to those concerning to the 79 medical and dental journals published from pakistan where the participation of women on editorial boards was 17 although pakistan has a 143144 rank in the gender equality index a study of 10 highimpact surgery journals over 20 years revealed that although the proportion of women increased from 5 to 19 men were more likely to retain their positions over time several studies in the field of medicine investigate gender differences in the composition of the editorial committees of medical journals in dermatology for instance committees of 25 journals were analysed over a period of 50 years finding that over all those years only 25 women have been appointed chief editors resulting in a ratio of 149 compared to the number of men a similar study was carried out in the area of anesthesiology the journal of cardiothoracic and vascular anesthesia was analysed between the years 1987 to 2019 it was found that the presence of women was 13 with an increase in participation from 25 in 1987 to 158 in 2019 in the same vein another study was conducted in the canadian journal of anesthesia finding that only 10 of the editorial board members were women another prestigious journal of the field of pharmacology has also been analysed in this sense zehetbauer et al carried out a gender analysis of the authors and the editorial board of the journal naunynschmiedebergs archives of pharmacology from the year 2000 to 2020 it was found out that there had been a substantial increase in the proportion of women in the editorial board since 2016 as the result of appointments by the editorinchief in the field of radiology another work analysed the most cited journals published in scimago journal rank in the usa identifying 9 journals for the study it was found that the representation of women with respect to men within the editorial boards was not representative according to the percentage of authors by gender in those journals being the participation of women in these committees of 24 another study on four prominent radiology journals over 40 years revealed that the presence of women was 159 compared to men and that no woman had been appointed chief editor of any of the journals analysed in the field of orthopaedic this aspect has also been studied it was found that the representation of women was of 39 in all the editorial board members analysed this percentage however increased from 08 in 1970 to 65 in 2007 in the area of psychiatry a random sample of 836 journal editorial boards showed a women presence of 304 other scientific fields show similar results to those of medicine furthermore several studies also estate the interest that this subject arouses in the field of pure sciences the percentage of women in the editorial boards of environmental biology and natural resource management journals was 16 in the case of ecology and evolution journals these percentages reach 30 as a matter of fact the percentages of presence of women in the committees are even lower in mathematics journals where they are quite underrepresented only 89 of the members of their editorial boards are women according to topaz and sen while in another study these percentages turn out to be as low as 57 in view of this situation some journals such as the journal chemistry decided to increase the number of women on their editorial boards in 2014 the number of women on its editorial board raised from three to five in the field of social sciences the interest in knowing the participation of women in the editorial boards is also evident for instance in marketing journals the participation of 24 of women in the editorial boards of was pointed out by pan and zhang while in the education journals in spain this figure reaches 335 the 50 topranked journals of political sciences were analysed in 2011 and it was found that 18 of the chief editors were women likewise an investigation of the editorial board members of 57 management journals between 1998 and 2004 revealed that 80 of the journals included in the study have 20 or less women on their editorial boards the percentage of women within the editorial boards of social science journals published in spain is 1961 in another similar study 33 physical education and sport journals from spain were analysed in 13 of them women presence in editorial boards did not even reach 15 and in 996 of them the chief editor was a man in 2003 the editorial boards of 19 latin american psychology journals indexed in wos were analysed showing that women only represent 323 of the 1189 board members in fact only in 3 journals the number of women on the editorial board was higher than that of men on another similar study the editorial boards of 36 economics journals from italy over a period of 26 years were studied it was found that in 11 of them there were no women and that in 14 they were included only as secretaries of the editorial board only 5 of them included women this value being equal to their representation in the academic profession during the literature review no evidence was found of studies carried out on the editorial boards in the arts and humanities journals in spain in the closest study found 131 journals from spain that were included in eight scientific fields of the web of science were analysed 10 of them were humanities journals in which the presence of women was found to be of 2381 this scarcity of this type of research in the field in spain makes it relevant to investigate in some of the areas related to this category as table 1 shows we have not found any bibliometric studies on the presence of women on the editorial boards of journals within the field of language and linguistics thus we believe that it is relevant to investigate whether gender patterns observed in other fields of knowledge are reproduced in these group of journals in 2012 the scientific production of spanish authors within the language and linguistics field comprised 45 of all articles indexed in scopus the bibliometric studies carried out in this area have been oriented to the identification of scientific producion by authors research centers or cowords in spain during the academic triennium 20172018 to 20192020 the number of students enrolled in the degrees directly related to linguistics has been 127801 out of those 737 were women compared to 2682 of men in the case of the teaching and research staff during the 20192020 academic year the number of faculty members in these degrees was similar 603 of women compared to 397 of men the abovementioned background as well as the situation of the spanish scientific production in the language and linguistics field and the high percentage of women studying degrees related to this field confirm the relevance of this area of knowledge hence it is noteworthy to determine the level of responsability of women in the management processes of scientific journals in spain objectives of the study this study aims to analyse the presence of women within the editorial boards and advisoryscientific boards in spanish journals indexed in scopus under the category language and linguistics the objective is to identify possible gender biases present in these boards materials and methods this work involves an exploratory study based on document analysis over an intentional sample of journals the unit of analysis used was the gender composition of the members of the editorial boards and advisoryscientific boards of the 54 spanish language and linguistics journals collected in the scimago journal rank which assigns the impact of journals indexed in scopus and pertaining to the 2018 edition this unit of analysis provided us with a larger sample as only seven art humanities spanish journals were found in the journal citation reports of the web of science however all seven journals are included in this study as they are also collected in the scimago journal rank and scopus the variables considered in relation to the editorial and advisoryscientific boards for each of the journals were the total number of members as well as the gender of each of the board members as well as the role played within the board firstly during the month of december 2019 the scimago journal rank website was consulted in order to collect the necessary data in this case journals within the arts and humanities category in the country of spain 54 journals were retrieved including 15 corresponding to the second quartile as well as 19 q3 journals 18 q4 journals and two journals without assignment subsequently the web pages of each journal were visited so as to collect information concerning their committees and their members as well as their gender this information was inserted in an ad hoc database the gender of each member was determined by their given name the gender was assigned directly in the database in those cases where the gender was clear as their given names were written in spanish in other cases there could ambiguous names or incomplete names thus in order to be able to correctly assign a gender a second search was conducted within the webpage of the home institution of this person this search was aimed to check their biographies as well as to check their pronouns for instance in spanish the abbreviations dr and dra are used to refer to a person holding a doctoral degree subsequently an excel visual basic application script was coded to assign a gender to each person this software searched for their first name in a database of names with their corresponding genders in similar way to frietsch et al this procedure unambiguously identified the gender of each person in 98 of the cases matching the assignments given manually except for occasional errors that were corrected afterwards we have set 005 as significance level for all statistical tests conducted results table 2 shows the frequencies and percentages of authors who are members of the committees according to their gender for each of the journals analysed the data presented in table 2 reveals that most journals show some gender inequality mostly with male predominance women form the majority in only 19 journals whereas in 5 of them there is absolute parity between men and women revista de dialectologia y tradiciones populares porta linguarum dialectologia miscelanea sefarad and trans it is also noteworthy that the two journals with the lowest number of members on their editorial boards have 100 and 75 women respectively both journals are placed in the second quartile the total number of members of the editorial boards of the 54 journals analysed is 640 of which 364 are men and 276 are women five male editors participate in two different editorial boards the average number of members of the editorial boards is 118 the average number of men per journal is 67 whereas the number of women per journal is 51 the wilcoxon signedrank test to check whether the median of women proportion was 50 gave a pvalue of 0087 so the observed differences were not statistically significant as for the distribution of the gender of the editorsdirectors of these journals there is a higher representation of men as compared to women as shown in table 3 the binomial test to contrast whether the percentage of female editors is statistically lower than that of men results in a value of p 066 thus the differences found are not statistically significant with respect to the gender of the editorsdirectors and its relation to the impact of the journals analysed it is noted that there is also a higher representation of men in all quartiles in journals where a sjr quartile has not yet been assigned the editors are always male as for the editorial boards it can be noted that the journals belonging to the fourth quartile are the ones with a higher percentage of women performing this role thus showing a wide gender gap the journals belonging to the second and third quartile show small differences in this respect in the two journals that have not been assigned sjr values yet men double the number of women in the role of editor it is observed that at a purely descriptive level the higher the quartile the lower the number of women on their editorial boards the chisquare test was used to check if there are significative differences in the proportion of genders according to the journals quartile results there is no statistically significant evidence as the value determined was p 096 the advisoryscientific boards of the journals analysed are formed by 1179 subjects men represent 5606 of their members while women represent 4394 of them the average number of members on these committees is 218 considering the position of the journals in their quartiles it can be appreciated that the gender gap decreases in those corresponding to the third quartile and in those journals which have not been assigned sjr values yet with a difference of 1012 in the second and third quartiles this gender gap increases as shown in fig 2 in only 9 journals there are more women than men within the scientific board the median test was used to check whether there are differences in the number of members of the editorial board according to the gender of the editor this test resulted in a value of p 04129 therefore there is no statistically significant evidence of the abovementioned trend if the values obtained in the present research are compared with those of different studies where this topic has been addressed it can be observed that in this field the value determined were higher unlike the value obtained for education journals which are in turn the highest in the whole area of knowledge of social sciences in addition the value obtained in this study is much higher than those obtained in the studies carried out on journals in the field of medicine where the highest percentage was found within radiology journals conclusions one of the main findings of this study has been the disparity found in the size of the editorial boards of the journals analysed as the number of members varies from only 4 members to 35 within the area analysed in this research the spanish language and linguistics journals it is noted that number of men and women present in their editorial boards is practically identical in view of the above it can be stated that these editorial boards do not show a gender bias which also means that they make a substantial difference with respect to the editorial boards in other fields of knowledge this has also become evident when analysing the figure of the editordirector of these journals as all the differences observed are not statistically significant and may be due to chance compared with other fields from social sciences the area object of study shows higher gender equality in terms of participation of women on eb the second place is held by the field of education where the percentage of women was 335 in 2002 state this may imply in a sense a benefit for all women as the occupation of prominent positions in committees and academic bodies can make them become models and references for young women who are starting their academic careers we consider that this study could be extended to journals of the same category at an international level thus it will be possible to prove if the results obtained form an identifiable pattern of the journals belonging to this area or if they follow a local pattern that could be motivated in turn by the policies on gender equality promoted in spain limitations our study has certain limitations which are outlined in this section as some editorial board members belonged to more than one journal they were quantified for each journal this may have had a minor or nonsignificant impact on the results moreover we did not consider the particularities of each journal such as the characteristics of their subfield of knowledge or the proportion of men and women working in it nor it was taken into account if the journal grants any kind of financial reward for being a member of the editorial team also as some researchers claim it is not possible to know how many men and women the journals have invited to participate in their committees or how many have declined the invitation and what their gender is

many international studies have pointed out the underrepresentation of women on editorial boards of both science and social science journals their presence as editorial board members is relevant as they influence and reflect the policies of the journal itself this study analyses the participation of women on the editorial boards of the spanish language and linguistics journals in scopus to this end 54 journals indexed in scopus were analysed thus discriminating the gender of all members and the role that each member plays on the editorial board the results show no significant differences in the participation of men and women in these editorial boards it was not found any evidence of gender bias in these journals

introduction the world is experiencing a crisis of physical inactivity with almost 80 of adolescents not achieving the recommended 60 min of daily moderate to vigorous physical activity for health 1 in this context transportation as a daily necessity to move from one place to another represents a promising domain to promote the accumulation of physical activity in children and adolescents in a convenient and habitual manner 2 specifically active transportation tofrom school is an opportunity to integrate physical activity into childrens and adolescents routines 3 active transportation comprises nonmotorized travel modes like walking cycling or riding a scooter among others 4 the use of these active modes leads not only to health benefits such as greater levels of cardiorespiratory fitness 35 and better cardiometabolic health indicators 6 among children who actively commute but also to other cobenefits such as better mental health outcomes 78 greater interaction with their environment 9 and reduced transportationrelated emissions and pollution 10 despite these benefits current evidence suggests that this behaviour is declining in many countries 11 in the same way that physical inactivity prevalence varies widely across countries 1 a wide variation in active transportation could be expected these variations represent an opportunity to identify those countries that are succeeding with active transportation behaviours and those that require action to increase active transportation or prevent a decline in this behaviour however to the best of our knowledge the few international comparisons of data on active transportation among children and adolescents include mostly small groups of countries or the availability of national representative data is limited 11 12 13 therefore the global matrix 30 of report card grades on physical activity among children and youth provides an opportunity to describe and examine the global situation of active transportation for the first time 49 countries from all continents reported data on an active transportation indicator at the national level 14 the aims of this study were to compare the prevalence of active transportation among children and adolescents from 49 countries participating in the global matrix 30 to identify a set of profiles to group the countries according to their prevalence of active transport and sociodemographic variables and to discuss policies and practices implemented across different countries to increase active transportation materials and methods the global matrix 30 was an international initiative released in 2018 and led by the active healthy kids global alliance this project brought together 513 researchers and physical activity leaders from 49 countries around the world 15 all the participating countries followed a harmonized process to develop report cards on the physical activity of children and youth a detailed description of the countries involvement and the process to develop the report cards has been published elsewhere and is briefly described here 14 in each country national report card committees gathered the best and most recent national surveillance data available up to 2018 to inform and grade ten specific indicators related to physical activity among children and adolescents overall physical activity organized sport and physical activity active play active transportation sedentary behaviours physical fitness family and peers school community and environment and government 14 the analyses presented in this paper are focused on the active transportation indicator according to the benchmarks proposed by ahkga to harmonize and guide the development of the report cards the active transportation indicator was described as the percentage of children and youth who use active transportation to get to and from places 14 report card leaders were instructed to inform this indicator by the best preferably nationally representative data available for children and adolescents between five and 17 years and a grade was assigned according to the prevalence following a common rubric established by the ahkga the prevalence of active transportation reported by each country and the related details presented in each report card including policies practices strategies to improve the grade and research gaps were extracted from the report cards and from related publications in english spanish or french including brief reports posters and peerreviewed articles these publications were reviewed and relevant information was summarized by two of the authors of this manuscript based on the grades provided numerical equivalents were assigned and average estimates of the grades for active transportation were calculated at the global level and by groups of countries according to their level of development determined by the human development index the hdi is a composite index created by the united nations development programme to rank countries based on key dimensions of human development such as education life expectancy and gross national income per capita 16 hdi ranges from 0 to 1 and for the present analysis we used the continuous index and a categorical variable that classified countries in three categories low and medium high and very high 16 it was included as a variable of interest in this analysis based on the variability in active transportation observed across hdi clusters in previous analysis of the global matrix 14 also the gini index for each country was retrieved from the world bank estimates the gini index provides a measure of inequality in income distribution it ranges from 0 to 100 17 the gini index was included in this analysis considering previous international evidence that has shown that income inequality is a relevant variable related to physical activity levels and taking into account the importance of socioeconomic inequalities in transport as an essential activity for economic and social development 1819 a latent profile analysis was conducted to identify groups or profiles of countries based on the numerical grades for active transportation and the two sociodemographic variables at the country level the hdi and the gini index lpa is a probabilitybased statistical procedure that allows to identify classes or profiles that group observations sharing similar patterns of the variables of interest 20 the analysis was performed to look for the best model solution for one to five possible profiles models were compared to choose the solution with the best fit based on the akaike information criterion sampleadjusted bayesian information criterion and the bootstrapped likelihood ratio test as indicators of model fit all statistical analyses were performed using sas 94 and r the tidylpa package 21 was used for the lpa results a total of 47 countries in the global matrix 30 had sufficient evidence on active transportation to assign a grade the grades ranged from a in japan nepal and zimbabwe to f in chile the global average for active transportation was c the average grade by hdi was c for low to medium hdi countries c for high hdi countries and c for very high hdi countries as previously reported by aubert et al 14 the hdi of the included countries varied from 0448 in ethiopia to 0985 in jersey according to the gini index the country with the most unequal distribution of income was south africa with a gini index of 63 while slovenia had the lowest inequality score with a gini of 254 table 3 presents the prevalence and rationales behind the grades for each country as well as the sources and characteristics of the information reported active transportation among children and adolescents varied between 15 in chile and 86 in japan and nepal among the countries that assigned a grade for active transportation 83 did not provide details of the prevalence stratified by sex in the majority of countries that reported data by sex the prevalence of active transportation was slightly higher for males more than half of the countries reported data for both children and adolescents however the age groups included varied from one country to another most countries only included data on school trips and only two countries clearly reported active transportation to other destinations regarding the direction of the trips about half of the countries reported active transportation to and from school or other destinations in more than half of the countries the frequency of active transportation reported was not clear the most common frequencies reported were daily typically or usually and on a regular basis regarding the source of information 64 of the countries used data from surveys and studies with national representativeness 85 used local studies and 19 used both local and national studies international surveys such as the global schoolbased student health survey 22 and the health behaviour of schoolaged children 23 were among the sources of information in seven countries the best lpa model grouped the global matrix 30 countries into three profiles according to the grades for active transportation the hdi and the gini index the threeprofile model had the best fit statistics according to the criteria proposed by nylund et al for model selection 24 the preferred model showed the lowest values for the aic sabic and the blrt and a significant p value for the blrt table 4 shows the descriptive statistics for the latent variables among the three profiles identified in profile 1 72 of the countries had active transportation grades below c 96 of the countries had a very high hdi and 72 had relatively low gini indices in profile 2 85 of the countries had active transportation grades equal to or greater than c all of them had a low to medium hdi and 43 had gini indices above 40 in profile 3 94 of the countries had active transportation grades equal to or greater than c 53 had a high hdi and 35 had a very high hdi and 47 had gini indices above 40 for countries with missing values in any of the variables of interest the lpa assigned a profile based on the values available for the remaining variables figure 1 presents a plot of the scaled data for the three profiles index and the gini index varied notably between variables therefore they were converted to zscores to be expressed in the same range of values and to ease their graphic depiction the availability of details related to active transportation in the report cards beyond the reported prevalence varied across countries table 5 summarizes the information provided by countries in terms of practices and policies strategies proposed to improve the grades and research gaps identified by expert groups in each country twentyfour countries provided at least one of these details the policies and practices identified by the expert groups included school siting policies transport policies that prioritize active modes of commuting walking challenges and special events and multicomponent programs that comprise educational strategies enforcement of regulation to improve traffic safety and providing infrastructure and resources at several levels the most common topics in the strategies proposed to improve the grades were improving safety conditions providing supportive infrastructure developing informational and education strategies and involving parents schools and communities in the promotion of active transportation several research gaps were identified but the most frequent across countries was the need to study active transportation to destinations other than school the range of values for the active transportation grade human development index and the gini index varied notably between variables therefore they were converted to zscores to be expressed in the same range of values and to ease their graphic depiction the availability of details related to active transportation in the report cards beyond the reported prevalence varied across countries table 5 summarizes the information provided by countries in terms of practices and policies strategies proposed to improve the grades and research gaps identified by expert groups in each country twentyfour countries provided at least one of these details the policies and practices identified by the expert groups included school siting policies transport policies that prioritize active modes of commuting walking challenges and special events and multicomponent programs that comprise educational strategies enforcement of regulation to improve traffic safety and providing infrastructure and resources at several levels the most common topics in the strategies proposed to improve the grades were improving safety conditions providing supportive infrastructure developing informational and education strategies and involving parents schools and communities in the promotion of active transportation several research gaps were identified but the most frequent across countries was the need to study active transportation to destinations other than school since 1953 japan has a walking to school practice resulting from the implementation of the article 49 of the school education act which regulates the siting of public schools in urban areas of japan this article establishes that the commuting distances are 4 km for elementary schools and 6 km for junior high schools based on these the boards of education must ensure that children attend to schools located within those distances to allow children to walk to school 14103104 not reported research on active transportation to destinations other than schools 104 azimbabwe 2 not reported 1 through public health messages to highlight the benefits of active transportation and reduce the prestigestatus symbol associated with motorized transportation 2 implementing policies that encourage and provide safe and walkable neighborhoods and bike lanes etc 105 there is a need of data reporting the time invested in active transportation and distance to and from school as well as research data on the correlates of active transportation and more recent data is required 105 b finland 3 not reported not reported there is no comparable published data available about active school commutes for upper secondary students when the distance between home and school is less than 5 km more information is needed about active transportation to other destinations 106 b hong kong 3 the high density of hong kong could be one of the factors facilitating active transportation to school since most districts in hong kong are highly selfcontained children can attend schools located at walkable distance from their home 107108 1 encouraging active travel to destinations other than school may provide additional health benefits for children and adolescents 2 promoting cycling to and from school and other destinations in districts with a bicycle track 107108 data about active transportation to destinations other than school as well as the relationship between active transportation physical activity and healthrelated outcomes also data on the duration of active travel trips is required 107108 b colombia 3 in bogota the capital city of colombia the program bike to school is implemented in public schools to promote cycling as a sustainable mode of transportation to school and other destinations in the city the program was created in order to address the barriers to access to education and to decrease the dropout rates bike to school program includes the following strategies bicycle loan workshops on skills and abilities to ride a bicycle basic mechanics and road safety education participatory mapping of safe routes daily trips from a meeting point to school with adult supervision and extracurricular activities to develop responsible behaviours in the roads and to visit other destinations of interest in the city 109110 another promising practice to encourage walking and cycling but with recreational purposes are the open streets programs or ciclovias colombia currently has 67 of these programs that close main roads to motorized vehicles and open them for leisure activities on sundays and holidays 109111 walking and cycling are the main activities performed by children who attend ciclovia in bogota 112 also colombia has a specific law to support the use of bicycles as the main mode of transport at the national level this law establishes the responsibility of public transportation systems to allow multimodal trips through the provision of bikesupporting infrastructure and encourages schools to implement programs to promote cycling 113 1 improving safety conditions and infrastructure to keep promoting and maintaining active transportation as a desirable behaviour since early ages 109 not reported the national transport policy in nigeria is under review with the aim to strengthen the inclusion of nonmotorized transport infrastructure and to create better nonmotorized transport options for urban residents this review is the result of a workshop on streets design led by the federal ministry of transport in 2017 and is a good example of the concerted efforts to improve the conditions for active transportation in nigeria 114115 another example is the nonmotorized transport policy developed in lagos which aims to prioritize walking cycling and public transportation as the main modes of transport 114 this policy specifically addresses active transportation to school through two strategies public awareness through the creation of a curriculum about road safety and benefits of active transportation for primary and secondary school students and regulations that include the creation of route plans for students to go to school and the implementation of access and safety measures such as speed limits traffic calming infrastructure and school zone signaling 116 not reported not reported c ghana 2 the community day senior high schools built in various districts in ghana seem to be encouraging active transportation to school the students who attend to this schools usually walk to and from school every day some of them covering more than two kilometers 117 118 not reported data on all age groups and stratified by age group and sex is desirable for future surveys 118 c brazil 3 not reported local authorities should be encouraged to create a monitoring system to generate standardized and detailed reports on active transportation to school to support planning and evaluation of public policies 119 data on time invested in active transportation the distance to the school and other environmental and mobilityrelated factors such as bike paths traffic and conditions of the city is lacking 52 c ethiopia 2 not reported 1 building sidewalks to encourage active transportation in all cities in ethiopia 2 encouraging and supporting children and adolescents to travel to and from school through active transportation 120 active transportation specific studies in ethiopia are required 120 c scotland 1 not reported not reported no data available on active commuting to and from places other than school 121 c sweden 1 a national cycling strategy has been adopted in sweden to improve safety and increase cycling 122 the strategy aims to increase cycling through five action lines creating more bicyclefriendly municipalities focusing on various types of cyclists giving higher priority to bicycle traffic in community planning building more functional and userfriendly cycling infrastructure and strengthening research an innovation on cycling 123 not reported not reported strategies to encourage active travel to school are needed especially for girls younger children and older adolescents 126 this strategies should have a multisectoral y culturally appropriate approach including urban planning initiatives a the school and community level social marketing campaigns and family support 127 nationally representative data on active transportation to school and other destinations that is comparable between countries and across time is desirable 127 ctaiwan 1 not reported local governments and schools should work together to create a safe and convenient environment for active transportation 128 research on the contribution of active transportation to overall physical activity in children and adolescents and about motivations and barriers for active transportation is needed 128 the australian capital territory has implemented the ride or walk to school program since 2012 aiming to build the capacity of primary schools to support and promote active travel to and from school the program was designed with a participatory approach including students and different stakeholders the strategies of the program include resources for teachers and students provision of bikes and helmets safe routes maps workshops to increase skills and four annual active travel events this program was expanded to high schools since 2016 129 in western australia the department of transport implemented the program your move schools this is a communityfocused program that promotes active and sustainable transportation providing teaching resources expert advice and access to funding to promote active transportation through bike education workshops wayfinding bike supporting infrastructure like bike shelters bike repair stations bike skills tracks and bicycle parkings 129 1 encouraging families to active commute at least part of the way promoting the use of park and walkridescoot zones away from school grounds to reduce traffic 2 creating and promoting safe routes to schools and engage schools to promote their use 3 creating greater awareness of actual distances between home and school and the travel time for active modes 4 highlighting the benefit of students travelling to school carrying their school bags as an opportunity to be active while carrying a load which could contribute to improve their muscular fitness 129 1 nationally representative data for primary and secondary students 2 data on the use of active transportation to other destinations 3 data on the use of multimodal transport combining active transport with public transport 4 research about how far families and children are willing to travel using active transportation 129 in the northern territory the nightcliff walk and wheel initiative is aimed at encouraging students to walk and cycle to school this is a local project in two dense suburbs lead by principals and parents from four schools the project has a focus on roads safety for children and has implemented activities such as the ride2school days increasing cycling to school 129 d wales 1 the report card mentioned the following initiatives led by charities to promote active travel to school 1 active journeyssustrans school active travel program promotes active transportation through different actions like providing support to schools to develop active travel plans delivering activities and lessons offering free incentives to promote active travel providing resources and online travel challenges for the school community and rewarding schools with the school mark award for achieving excellence in active and sustainable travel 130 2 living streets walking initiatives this charity has two main strategies for schools the wow yearround walk to school challenge and the fivedays walking challenge both of these aim to engage primary and secondary students to walk to school encouraging them with an interactive travel tracker and the provision of incentives at the end of the challenge this charity also encourages the celebration of the walk to school week in may every year 131 not reported more research is needed on how children and young people travel to other places including shops parks and friends or relatives houses 132 d guernsey channel islands guernsey has an integrated transport strategy in place that promotes active travel with the aim of having a positive impact on the environment and the populations health 133 the onisland integrated transport strategy aims to encourage active travel followed by the use of public transport and to reduce the use of private motor vehicles this strategy was initially planned to progressively advance to a taxation policy for high emission vehicles to support the promotion of active travel through the implementation of the integrated transport initiative that supports active travel 133 not reported however there are other actions in this strategy aimed at increasing active travel to school such as bikeability training at primary schools increasing the investments in walking and cycling infrastructure to improve safety for active commuters revising the speed limits to enhance the safety of vulnerable populations using active travel and developing and implementing travel plans for schools 134 nationally representative samples for children and adolescents and on all active transportation means are required to gain a better understanding of this indicator 135136 dcanada 1 in ontario the minister of education expanded the funding for initiatives that improve the cognitive physical social and emotional wellbeing of students specifically walking school buses and bikingtoschool programs have benefited from this increase in the funding 137 4 more research is needed on the use of mixed modes of transportation to and from destinations 137 in 2017 three organizations in canada created an active transportation alliance to advocate for the adoption and funding of a national active transportation strategy 137 however this strategy is not yet in place 7 encouraging schools to implement dropoff spots from which driven children could safely walk to school in groups 137 dunited states 1 safe routes to school is a movement with initiatives at the regional state and local levels that aims to promote walking and bicycling to school improving safety health and physical activity levels actions at the local level incorporate the six es integrated approach education through the provision of training in skills and knowledge to walk and bicycle safely and teaching the benefits of active transportation encouragement to motivate children to travel actively through events and activities engineering to improve streets and neighborhoods in order to make them more convenient for walking and bicycling enforcement of safety regulation evaluation of the success and opportunities to improve the initiatives in place and equity to ensure that the program benefits all demographic groups actions at the regional and state level are focused on finding funding and ensuring the proper use of the resources invested in the program at the federal level the safe routes partnership advocates for policy and funding support and provides expert help ideas and resources for the leaders at all levels 139 discussion our results suggest that about half of children and adolescents use active modes of transportation to get to and from places mainly to andor from school however a pooled estimate of the global prevalence of active transportation cannot be calculated from the global matrix 30 data for reasons that will be discussed below despite the clear gradient in average grades according to hdi that has been discussed in previous publications 141 142 143 our results show variability within hdi groups and the lpa allowed us to examine the clustering of this sample of countries according to three variables of interest comparability of data there was wide variability between countries in the prevalence of active transportation and high involvement in this behaviour was reported across countries with very different socioeconomic contexts however the data reported by the countries presented in table 3 show important methodological differences that should be accounted for when comparing the prevalence of active transportation between countries one of the issues that can affect the comparability of data is the difference in the frequency of use of active transportation reported by the countries depending on the cutpoint used to define children as active travelers the prevalence will vary widely and the use of active transportation can be overestimated or underestimated similarly the prevalence may vary depending on the direction of active transportation assessed since different modes can be used to go to and from school as observed in previous comparisons of surveillance systems measuring active transportation the prevalence of active transportation varies greatly according to the construct assessed 144 in the group of countries included in this analysis the frequencies reported varied from daily to at least twice per week even when the source of information was the same survey different frequencies were reported 136 145 146 147 regarding the construct assessed the destination for active transportation is also relevant despite the broad definition of active transportation in the global matrix 30 benchmarks 14 most of the evidence available on active transportation in children is focused on the journeys to and from school as observed in this analysis and in previous literature 148 only ecuador and the united states reported the use of active transportation to other destinations which could suggest an underestimation of the involvement in active transportation in other countries since trips to places such as parks and other peoples homes are also relevant opportunities to engage in this behaviour 149 these findings point to a need for the development of harmonized and contextualized measurements our results are consistent with the findings reported by herradorcolmenero et al in a systematic review in which the formulation of a standardized question is proposed to overcome the heterogeneity in measures to assess active transportation 150 based on these insights initiatives like the global matrix and organizations like the ahkga can contribute to the improvement of surveillance systems for the evaluation of active transportation among children the global matrix initiative aims to better understand the global variation of certain physical activity indicators 14 specifically active transportation is one of the most strategic indicators in the global matrix 30 to contribute to this aim due to the low amount of inc grades and the good dispersion of grades across countries 14 however the availability of transportationrelevant contextual variables at the country level to understand these variations was limited therefore the lpa provides an exploratory approach to identify subgroups that share similar patterns of variables 20151 and provides a unique opportunity to identify the ways in which countries in the global matrix 30 cluster according to the grades for active transportation and contextual variables the identified profiles can be useful for the discussion of the different contexts in which active transportation needs to be maintained or increased a description of the three profiles is provided below country profiles for active transportation and sociodemographic variables profile 1 included mainly countries with a very high hdi and low income inequality mostly with a reported prevalence of active transportation under 50 mainly countries from north america europe and oceania were grouped in this profile while the countries with the lowest prevalence of active transportation were classified in this group it also included some countries with nonnegligible prevalence of active transportation such as the netherlands belgium and the czech republic this means that although all of these countries have a similar development level there are other relevant factors influencing active travel among children first some of these are countries where long distances between destinations and the perceived convenience of driving may undermine opportunities for active travel 102 152 153 154 second urban planning and policies that have prioritized people instead of cars as well as supportive infrastructure have made active modes a convenient and safe alternative to commute 155156 interventions in countries under this profile should aim to increase active transportation addressing the issues of distance and convenience attempting to discourage the use of motorized vehicles for short trips and trying to shift the social norms to consider active modes the default option for commuting as it occurs in many european countries a useful example among the policies reported in the report cards is the national cycling policy from sweden which aims to prioritize cycling in the community and municipalities planning 123 profile 2 grouped mostly countries with high prevalence of active transportation low to medium hdi and higher income inequalities in most of these countries access to motorized vehicles is limited and active travel is happening despite multiple safety concerns 157158 and the lack of supportive infrastructure 143 therefore for many families active transportation is likely to reflect necessity rather than choice 159 also many of the countries in this group report important differences between children from rural and urban areas 117120145 as suggested by a previous systematic review on active transportation in africa these differences could be indicative of the physical activity transition that these countries are experiencing 157160 in this context for the countries classified in this profile preserving active travel while providing improved safety and infrastructure conditions should be a priority it is important to design strategies to avoid the unintended consequences that economic growth can have on the mode of transport for children and adolescents a good example of the approaches needed in countries under this profile is the nonmotorized transport policy from lagos nigeria this policy aims to prioritize active modes of transportation over motorized options communicating the benefits and importance of active transportation as well as improving safety conditions for students using active modes to go to school 116 profile 3 had more variability in terms of hdi and income inequality however the relatively high prevalence of active transportation was a main feature in common between this group of countries some of the most successful countries in active transportation are grouped under this profile however the conditions in which it is happening are very different there are countries such as finland denmark japan south korea and hong kong where the use of active modes is supported by the design of compact cities school siting policies that ensure that children attend to schools located at a walkable distance from home and supportive infrastructure and regulations 103104108141155161 these factors have made walking and cycling safe options for the daily commuting conversely there are countries like colombia brazil mexico venezuela and south africa where active transportation is prevalent despite safety concerns the lack of supportive infrastructure and regulations and is likely to be a necessitydriven behaviour 526061 162 163 164 165 similarly to profile 2 almost half of the countries in this profile have a relatively high gini coefficient however this profile also includes countries with very low inequality such as finland and denmark income inequality has been previously documented as a negative correlate of physical activity and organized sports involvement 1419 notwithstanding the high prevalence of active transportation in both equal and unequal societies are consistent with literature that suggest that active transportation modes could be an opportunity to bridge the inequities in transportation 18 as well as in other domains of physical activity due to the diversity of contexts found in this profile different approaches are needed to promote or maintain active travel school siting policies that take into account the proximity between schools and childrens homes like those implemented in japan and hong kong 103104107 can be useful for growing cities also multicomponent strategies such as the bike to school program in colombia are a good reference for countries that aim to provide access skills and support to bike to school in safe conditions 110 furthermore ciclovias or open streets programs are a good model for countries where active transportation to school is already prevalent and aim to increase walking and cycling to other destinations in the leisure time 112166 regarding the strategies to improve active transportation it is concerning to find that major correlates of active transportation such as distance and the perceived convenience of driving are not mentioned among the strategies proposed by the report card teams future versions of the report cards as tools to communicate evidence to stakeholders should take these important factors into consideration in order to advocate for active transportation addressing its most important drivers our results can contribute to the call for measures of conditions related to all children wellbeing made by a recent commission sponsored by the who unicef and the lancet this commission identified that inequities and climate change are undermining childrens right to a healthy environment in both the poorest and wealthiest countries 167 given that the transportation sector accounts for almost 25 of global greenhouse gas emissions 168 local regional and national policymakers and practitioners should implement interventions that support childrens active transportation in all socioeconomic contexts strengths and limitations of the study strengths of this study include the availability of active transportation data from 47 countries from all continents and the harmonized selection of the best available evidence in each country our analyses contributed with a diverse context perspective to the emerging evidence on international comparisons of active transportation which has focused on specific groups of countries in previous studies 169170 although most countries reported nationally representative data on active transportation in some countries the best available evidence consisted of local data the main limitations of the study were the diversity in the quality of the data reported and the broad benchmark proposed for active transportation in the global matrix 30 which led to variations in the definition of active transportation across countries the important amount of missing data in the community and environment indicator and the heterogeneity of the data reported across countries did not allow to include it as a variable of interest in the lpa despite its relevance for active transportation for example including data on average distances for active transportation by country in future studies could strengthen the model and enrich the profiling of countries as distance is one of the most consistent predictors of active transportation also since we analyzed aggregated data at the country level a sample size of 47 is small and has limited power for the lpa this could partly explain the heterogeneity observed in the profiles mainly in profile 1 regarding the policies and practices reviewed there was also heterogeneity in the information reported across countries future versions of the global matrix can strengthen the guidance on desirable information to report in this regard such as the inclusion of active transportation to school in national education acts or their equivalents in each country the sample included in this study represents approximately 25 of the total countries in the world the inclusion of a larger sample of countries in future studies could provide a clearer picture of profiles according to active transportation and sociodemographic variables conclusions this work allowed for a deeper exploration of the active transportation information reported by all the countries participating in the global matrix 30 based on our findings we identified the need to standardize definitions of active transportation to be able to make more meaningful comparisons the lpa conducted allows for the inference that countries belonging to a specific profile have a greater probability of sharing certain characteristics among them compared to the countries belonging to other profiles given the variation by geographic region and even hdi this approach is useful for identification of more meaningful groupings that can facilitate the crossfertilization of efforts to promote active transportation and therefore to power the movement to get kids moving as is intended by the global matrix initiative 171 the active healthy kids global alliance can contribute to improving active travel surveillance providing guidance to countries involved in future versions of the global matrix a more comprehensive approach to active transportation surveillance that considers duration distance frequency direction other destinations than school and the contribution of active transportation to school to overall active transportation could improve the understanding of this behaviour and its potential to increase overall physical activity

this article aims to compare the prevalence of active transportation among children and adolescents from 49 countries at different levels of development the data was extracted from the report cards on physical activity for children and youth from the 49 countries that participated in the global matrix 30 initiative descriptive statistics and a latent profile analysis with active transportation human development index and gini index as latent variables were conducted the global average grade was a c indicating that countries are succeeding with about half of children and youth 4753 there is wide variability in the prevalence and in the definition of active transportation globally three different profiles of countries were identified based on active transportation grades human development index hdi and income inequalities the first profile grouped very high hdi countries with low prevalence of active transport and low inequalities the second profile grouped low and middle hdi countries with high prevalence of active transportation and higher inequalities and the third profile was characterized by the relatively high prevalence of active transportation and more variability in the socioeconomic variables promising policies from countries under each profile were identified a unified definition of active transportation and contextualized methods for its assessment are needed to advance in surveillance and practice

introduction human migration is a complex behavioural decision shaped by social economic demographic and ecological conditions of the environment within which an individual inhabits while not all migration is the result of a strategic choice the decision to migrate can be considered an adaptive strategy similar to livelihood diversification in the context of adverse environmental conditions or risks the migrationadaptation discourse commonly infers that voluntary migration in response to imminent or actual environmental stress is a strategic decision that reduces climate change risks within a geographic area particularly in populated coastal regions prone to rapidonset hazards such as cyclones however international and domestic migrants collectively comprise less than 16 of the worlds population suggesting most people remain in place the cognitive processes behind the decision to stay in hazardprone areas are likely just as complex as those leading to migration but there are comparatively fewer studies on the use of voluntary immobility as an adaptive strategy in response to environmental risk having the aspiration and capacity to remain in place when one is capable of migrating differs from being trapped in a location due to resource constraints or place attachment rather intentional nonmigration is a form of voluntary sedentarism sedentarism is commonly understood to be an adaptation that arises from a persons desire to stay home in contrast to migration nonmigration can be defined as spatial continuity in an individuals centre of gravity over a period of time another understudied dimension of environmental migration is the role of slowonset hazards in the decision to migrate or stay despite these being more globally widespread than rapidonset events such as cyclones particularly in lowlying coastal regions both slow and rapid onset refers to the speed of a hazard occurrence rather than the temporality of the impact of such hazards on affected communities here we consider cyclones to be rapidonset phenomena because they form make landfall and dissipate within days by contrast saltwater intrusion and drought related to climate change are examples of slowonset environmental hazards that are pervasive in coastal areas but may take months or decades for the cumulative impacts to manifest although the effects of a single cyclonic storm may persist for years the impacts of a discrete storm event are relatively abrupt compared to the effects of climaterelated salinization or drought additionally sediment trapping in channels or reservoirs arising from feedbacks with the built environment can take decades to accumulate before it impacts accretion erosion navigation and water flow in lowlying coastal zones both slowand rapidonset hazards can cause damage or complete loss of cultivatable land though their onset rate may influence perceptions that contribute to migration decisions overall the influence of environmental conditions on migration decisions is increasingly acknowledged by migration scholars while these authors link migration to environmental conditions outstanding questions remain how do environmental conditions factor into the decision to remain in place how does the awareness of gradually changing environmental conditions particularly for rural smallholder farmers who depend on predictable soil and water conditions to maintain their livelihoods motivate the decision to remain at home if the same factors influencing migration also guide the decision to remain in place then nonmigration decisions are likewise related to contextand personspecific opportunities associated with livelihood resilience and the capability and aspiration of not migrating more work is needed to understand the motivations perceptions and cognitive processes behind the decision to remain in place particularly in agriculturallydominated coastal regions where slowonset hazards are threatening water and food security this study contributes to this knowledge gap through an investigation of the multiscalar factors contributing to nonmigration decisions in agriculturaland fisheriesdominated coastal communities in bangladesh we draw on a theory derived from health psychology the protection motivation theory of rogers to frame the role of fear and personal appraisal of coping ability in nonmigration decisions we used multistage sampling to collect household survey data and key informant interviews from two districts of coastal bangladesh where natural and anthropogenic hazards have resulted in soil salinization and inchannel siltation over decadal time scales the pmt is then applied to examine the social economic institutional and ecological drivers shaping an individuals cognitive process when the decision to remain in place are made this approach allows us to investigate how people view their ability to cope with the risks associated with slowonset environmental hazards and how these contribute to nonmigration decisions nonmigration vs the opposite of migration nonmigration is often treated in mobility studies as the contingency or default state when migration is not feasible neoclassical theory of migration states that the decision to migrate is the result of a rational calculation of the costs and benefits of moving in this context nonmigration is the outcome when the costs of migrating outweigh the benefits of staying as though the factors that lead an individual to choose to migrate are simply the inverse for the decision to remain in place building on an increasingly structural approach to migration massey et al argue a component of a cohesive migration theory is the aspiration to migrate their suggestion provides insight into how nonmigration may be understood as an intentional and deliberate behavioural choice rather than the opposite of migration both migration and nonmigration can be seen as functions of individual aspiration and capability where capability refers to the ability to aspire as well as the ability to realize an aspiration that is those who aspire to migrate are not always capable of realizing this aspiration for many there is no agency involved in the decision to migrate or to stay black and collyer introduced the term trapped population to describe populations who would like to migrate but are incapable of doing so because they have limited economic resources and social connectivity the distinction between involuntary or forced immobility selectively being left behind while another member of the household migrates and voluntary sedentarism is that in the latter both an aspiration and capacity to remain in place are present other limits and barriers to adaptation through migration arise from psychological views cultural milieu and locational disadvantages resulting in a kind of forced nonmigration this is distinctly different from intentionally opting to remain in place when the capability to relocate exists particularly in areas where environmental hazards are commonplace an alternative motivation for migration is described by the new economics of labour migration theory which suggests that some members may migrate to benefit the remaining household member that remain in place through the sending of remittances however the nelm has been criticized for its limited applicability in nonmigration research nonmigration also encompasses translocal livelihoods whereby some people within a community temporarily and seasonally migrate mainly for economic reasons yet return and therefore remain connected to their origin community in this instance the members of a household who are left behind may benefit from sending a seasonal migrant out of the community to earn money as a way of diversifying the households livelihood portfolio other theories suggest that the social and cultural milieu of a community are the primary factors holding people to a place which implies a nonmigration decision is related to place attachment rather than the outcome of a rational costbenefit calculus these theories get closer to framing nonmigration as a conscious behavioural choice yet still present the aspiration to migrate as universal analytical framework scholars have applied diverse theories and conceptual frameworks to understand cognitive behaviour as it relates to migration including the stressthreshold model the residential satisfaction model and the theory of planned behaviour the stressthreshold model suggests that in most cases highly satisfied people would not consider migrating despite the fact that they may be better off somewhere else and the decision to migrate is an outcome dependent upon a calculation weighing the costs and benefits of leaving similarly the residential satisfaction model explains that intentions of migration or nonmigration depend upon residential satisfaction within a community the theory of planned behaviour describes the relationship between behavioural intention and actual behaviour particularly the attitudes toward a behaviour subjective norms and perceived behavioural control the theory of planned behaviour considers social influence such as social norms and normative belief but it does not consider how economic and environmental factors may influence an individuals intention to perform a behaviour and also does not consider that the behaviour can change over time another theory that could help explain migration behaviour the terror management theory claims that people protect themselves from death anxiety by maintaining their cultural worldviews and selfesteem recently tmt is employed to assess the impact of terrorist incidents on the desire for immigration in european countries however tmt considers the anxietybuffering factors for analysing a psychological disorder that hampers the decisionmaking ability of the individual in contrast to these cognitive behaviour models the protection motivation theory posits that both anticipated risks and action through either coping or adaptation influence individual cognitive behaviour the pmt was first introduced by rogers and used in social and health psychology to explain the effect that health communication in the form of fear appeals has on a patients choice of treatment rogers claimed that people protect themselves based on the perceived severity of a threatening event such as disaster or disease the perceived probability of the occurrence of the threatening event the efficacy of the recommended preventive behaviour eg belief that adopting a certain behavioural response will be effective in dissipating the threat and perceived selfefficacy eg the belief that the individual can successfully perform the coping response thus the basic concept of pmt is that selfprotection is achieved through a process that includes appraisal of both the threat and an individuals ability to cope with it the pmt was later expanded upon by maddux and rogers tanner et al floyd et al clubb and hinkle and wong et al to include the influence of risk and protection choice perceptions on decisionmaking the pmt has since been used to explain behavioural choice in information technology and security criminal justice studies and climate change adaptation strategies according to rogerss original theory people facing risk engage in adaptive behaviour through two interlinked cognitive processes evaluation of the occurrence probability and severity of a threat and perception of the effectiveness of a coping response and ones ability to adopt it perceived risks and coping responses are assessed prior to an individual choosing an adaptation strategy the strategy chosen depends on the skills or resources that an individual has access to which in turn frames an appraisal of the environmental risk and the potential responses that is the pmt consists of two possible techniques that an individual may use to link perception to behaviour which is not common for other behavioural theories such as the stressthreshold residential satisfaction or planned behaviour theories first the environmental risks appraisal technique clarifies the severity of and vulnerability to threats and the intrinsic and extrinsic rewards received from different behavioural responses second the adaptationresponse appraisal technique emphasizes the role of individual beliefs in a persons ability to respond to perceived risks ie selfefficacy response efficacy and response costs the technique used will depend upon an individuals experiences knowledge social economic and institutional supports and demographic characteristics since extreme weather and climatic events increase environmental risk and have the potential to impact peoples living environment it is assumed that coping and adaptation strategies adopted in response to these are based on risk assessments and resources in the context of environmental events migration or nonmigration are adaptation strategies that are embedded in an individuals risk appraisal and response capacity accordingly the pmt has been used to explain the perceptions of previous flood experience the risk and perceived ability to cope with future floods and perceived efficacy and costs of both selfprotective behaviour and nonprotective responses in another example martin et al employed pmt to understand riskmitigating behaviours undertaken by homeowners in the context of wildfire management pmt has also been widely used in understanding individual behaviours of people exposed to landslides drought and sealevel rise however to our knowledge this is the first time that pmt is applied to explain the role of fear appraisal in nonmigration decisions where slowonset hazards are drivers of environmental migration there is a positive relationship between migration intentions and hazard risk perceptions for example in the case of floods cyclones and wildfires here we consider perceptions of slowonset hazards ie gradual salinization and channel siltation and how these influence migration decisions in southwest coastal bangladesh this area is vulnerable to fig 1 protection motivation theory and its constructs modified from grothmann and patt and xiao et al both rapidonset and slowonset environmental events and inhabitants lack the resources needed to sustain current livelihoods or shift to alternatives this study includes a crosssectional analysis of environmental economic and social dimensions of migration decisions as guided by the pmt to understand decisionmaking regarding nonmigration materials and methods site selection and participants previous studies of migration decisions have considered different spatial temporal social economic and political drivers of migration here a multistage sampling approach is used to select 200 households from four villages for individual household interviews villages were selected within three unions the smallest rural administrative unit in bangladesh in two coastal districts khulna and satkhira a union typically contains around 9 individual villages the four villages selected as study sites were initially identified through reconnaissance interviews geographic criteria for site selection were that villages must be located less than a kilometre from a major river or mangrove forest other criteria include the presence of widespread livelihood challenges associated with placespecific hazards and a history of sociopolitical shifts in this study we consider sociopolitical shifts to be an outcome of historical landuse change arising from the shifts in natural resourcebased livelihoods ie conversion of rice paddyland to shrimp farms in the 1980s inclusion criteria for purposively selecting respondents were that they must be at least 18 years of age selfidentifying smallholder farmers owning 2 ha of land and able to answer questions related to their individual household as well as the local environment there were 1948 households in the selected study villages considering 95 confidence level and a margin of error of 65 we interviewed 200 households maintaining equal sample distribution in four villages a detailed description of the sampling criteria is available in the supplementary document the questionnaire collects the information of a household therefore our analysis represents the household level information the rural households in bangladesh are primarily maleheaded we interviewed female members in the absence of the malehead at home and thus our analysis reflects the maledominated perceptions on nonmigration decisions however this is socioculturally grounded and acceptable at our specific study sites incomplete or implausible data were removed from the study on average respondents took 40 min to complete individual surveys ethics approval was obtained from dhaka university of bangladesh and the respondents were not compensated for their time environmental setting household surveys and key informant interviews were conducted at four coastal unions in khulna and satkhira districts of southwest bangladesh both districts lie within a moribund area of the delta that receives very limited if any freshwater and sediment from upstream river sources these districts encompass sections of the sundarbans reserve mangrove forest as well as cultivated delta plain that is now used for agriculture and aquaculture the forest and delta plain are dissected by 10 000 km of navigable tidal creeks on the order of metres to several kilometres in width twice daily mesotides ranging from 2 to 35 m convey sedimentladen water as far as 120 km inland from the coast through this intricate network of channels while rural farmers have adapted their livelihoods to regular tidal flooding in coastal bangladesh soil and surface water salinization has gradually increased throughout the coastal belt since the 1970s land outside of the sundarbans forest was slowly converted from rice cultivation to poorly managed shrimp farming in the 1980s which accelerated salinization and degraded soils farming switched to mixed riceshrimp production as market demand for rice increased in the early 2000s though soil fertility remained very low due to the two previous decades of intense shrimp cultivation compounding the deleterious effects of prolonged submergence of land with brackish water for shrimp cultivation was a reduction in freshwater delivery to the coastal region natural river migration construction of the farakka barrage on the ganges river and subsequent siltation of principal distributaries delivering freshwater to the study area have resulted in reduced dryseason flows allowing the salinity incursion to penetrate over 100 km inland the proximity of our study sites to the bay of bengal also exposes them to storm surges from cyclones that occur an average of once every 3 years storm tracks wind speeds and timing of landfall within the springneap tidal cycle collectively influence the height of storm surge the extent of saline water intrusion from storm surges magnifies the cost of storms to lives and livelihoods cyclones sidr and aila alone caused an estimated 19 billion usd in cumulative damage including crop losses in subsequent years due to waterlogging and persistent salinization of cropland approximately onethird of people affected by cyclone aila migrated out of the region implying that the majority of people chose to stay despite significant impacts to their livelihoods comparatively approximately 75 of louisianas population remained in place following hurricane katrina in 2005 to protect bangladeshs agricultural sector from salinity incursions related to coastal flooding widespread earthen embankments locally called polders were built around many inhabited island perimeters outside of the sundarbans beginning in the 1960s embankments were outfitted with sluice gates that could be raised and lowered to allow water to drain from fields at the end of the rainy season since their construction polders have prevented tidal flooding of cropland but have also restricted the deposition of sediment that normally sustains the elevation of the landscape consequently the interior of poldered islands throughout southwest bangladesh has compacted while channels outside the polders have silted up increasing vulnerability to flooding and water logging an estimated 600 km of channels have been disconnected from the main channel network through siltation creating 90 km 2 of new land in the region the few viable channels for delivering river water and enabling navigation are obstructed by shrimp farms and irrigation dams questionnaire and variables the questionnaire has ten sections focused on demographic information livelihood opportunities migration and nonmigration intentions landuse change infrastructure management governance and accountability environmental hazards adaptation incentives and socioeconomic conditions the questionnaire was adapted from the integrated social environmental and engineering instrument used by vanderbilt university and modified for our study previous literature focuses on place attachment and social capital as the main drivers of nonmigration we expanded on this to include questions regarding inheritance wealth and capital resources and strength of social networks in this section we describe the variables we measured and the weight assigned to each we measured risk perception from three perspectives perceived severity refers to how a respondent perceives relative changes in the salinity of water in the nearest tidal river and canal and to changes in river siltation perceived vulnerability refers to how a respondents wellbeing and economic situation has increased decreased or remained the same due to environmental changes these two variables are measured on a scale from 0 to 2 where 0 means decreased ie perceived no risks 1 means no change in perception of risk and 2 means increased ie perceived high risks hazard experiences explain the number of events in the last 5 years that affected the livelihood of both the respondents and their communities this variable was measured on a scale from 0 to 20 those who responded all those five types of hazards have impacted their livelihoods and communities receive a score of 20 and those who responded that nothing has affected their livelihoods and communities receive a score of 0 for completing the environmental risk appraisal in our pmt model we also consider the intrinsic and extrinsic motivations of the respondents that result in a conscious decision to stay rather than migrate intrinsic motivation is a reaction to external variables such as the local political situation or collective decisions and acts to either reinforce or diminish the decision to migrate in our study we consider intrinsic motivation to reflect how satisfied respondents are with decisions that affect all community members in their village it was measured on a scale of 0 to 5 where 0 is never satisfied and 5 is very satisfied extrinsic motivation can influence the decision to migrate or stay and is driven by external rewards including the respondents social status recognition for good work or political affiliation we consider extrinsic motivation to be a function of how influential the person is on community decisionmaking it is measured on a scale of 0 to 5 where 0 is not influential at all and 5 is very much influential the adaptation appraisal is derived by three significant variables response efficacy selfefficacy and response costs risktaking and handling risks influence migration intentions people take all kinds of longerterm risks for example they invest in land in a periurban place they move to a new location or they send their son or daughter away for education or work elsewhere we consider response efficacy as a variable that explains how easy or difficult is it for the respondent to accept taking risks such as these it is measured on a scale of 0 to 5 where 0 is very difficult and 5 is very easy similarly the selfefficacy variable measures whether the respondent strongly agrees or disagrees that his or her family can survive environmental changes that are affecting livelihood sources it is also measured on a scale of 0 to 5 where 0 is strongly disagree and 5 is strongly agree it is expected that those who agreed that they could manage to shift their livelihood activity due to environmental changes opt for nonmigration as an adaptation response costs refer to whether the respondent migrated before within or outside their community due to an environmental event and was recorded as either a yes or no sociodemographic and economic factors also influence the interplay between the factors of migration decisions following an extreme event for example education is usually positively correlated to migration since bettereducated people have a higher chance of making a living outside their community hunter et al describe that women have a higher risk perception than men and are more likely to migrate internally in response to environmental hazards whereas men tend to migrate longdistance additionally land ownership and income play a vital role in response to environmental hazards as studies indicate that landlords and people with greater sources of income do not migrate after hazards whereas resourcepoor people mostly migrate to nearby cities or communities for alternative income opportunities however many economically poor individuals are incapable of migrating in response to environmental events because they lack capital or social network strength or have limitations within the household related to family caregiving taking all of the above into consideration we included age education and income as control variables in addition to those that are relevant to the pmt we did not consider the gender of the respondent as a control variable as only 2 of respondents in our sample were female because of the culturally embedded maledomination of household decisionmaking instead we consider the numbers of female members in the family as a control variable data analysis the overall factors motivating nonmigration decisions across all of our study sites include place attachment social network and connectedness immobile capital and economic strength and access to financial resources and institutions however these factors differ at the individual household level the dependent variable in our analysis stems from the reasons motivating a respondent to remain in their village and has greater than two response options therefore we employed a multinomial logit model to analyse the determinants of the respondents intention to remain in place the response options are of four forms i have my own land to grow crops and can run my family eg land inheritance and ownership my relatives and extended family are living in this village eg social network i am economically welloff and can manage any economic crisis in my family eg economic strength and others we used others as a response option reference category the mnl analysis was conducted using spss package version 22 our independent variables are cognitive variables according to the pmt and socioeconomic variables are controlled variables usually the parameter estimates of the mnl model provide the direction of the effects of the independent variables on the dependent variable first we estimated the correlation among the independent variables to avoid the strong collinearity that may influence the regression results second we ran a baseline model with all independent variables that were selected in the pmt we used the chi square test to explain the relationship between two categorical variables in addition to this we employed a post hoc analysis of achieved power of all the pmt variables with respect to the dependent variable the results derived from g power 3192 show that the power score of the pmt variables lies between 082 and 10 where the threshold score is 08 results in the following section we describe the quantitative demographic characteristics of our study areas and determinants needed for conducting the pmt analysis qualitative information collected through key informant interviews has been interspersed to provide context to our quantitative results sample characteristics detailed demographic results from each village are presented in table s1 and key results are summarized here overall the mean age of respondents across all study sites is 493 years mean household female members in our sampling frame are 23 whereas the mean number of household members is 47 the overall religious identity of respondents is 35 muslim and 65 hindu while half of our study villages contain a mixture of both the other two are comprised of entirely one or the other that is 100 of respondents in badurgacha village in shovna union are hindu while muslims constitute 958 of respondents in basantapur village in mathurespur union the distribution of religious identity in our study does not reflect that of all of bangladesh which as of the 2011 census was reported at 89 muslim and 9 hindu the share of muslim and hindu population in khluna district is 776 and 224 respectively whereas in the satkhira district the share is 818 and 182 respectively this offset is due to the selection procedure of the study sites that is our selection criteria were based on geographic proximity to rivers or tidal channels and therefore the study villages experience livelihood challenges related to locationspecific hazards and have a history of landuse change ie widespread conversion of rice paddyland to shrimp farms adult literacy across our study sites averages 76 which is similar with the countrys overall literacy rate of 74 for adults over 15 years of age in 2018 the highest percentage of illiterate respondents in our study villages were in basantapur and the lowest in badurgacha mean income is highest in mandartala village in shovna union and lowest in basantapur village individual respondents in badurgacha own more land compared to other study sites and respondents of dhankhali village in munshiganj union owned the least quality of housing materials is also the lowest in dhankali which is very near to the sundarbans forest boundary respondents conveyed that this is due to high soil salinity and lack of quality building materials locally available materials such as golpata wood is harvested from nearby mangroves and used to construct houses the settlement history question reveals that a majority of the respondents family has lived in their community since before their grandfather whereas 105 since their grandfather 145 since their father and the remaining 145 of the respondents were the first members of their family to move into their present community these results do not significantly influence the nonmigration motivation with regard to the motivation behind decisions to remain in place land ownership and its related farming opportunity are reported as the main reasons for nonmigration followed by land inheritance and strong local social ties economic strength and others these results do not significantly differ across the four study villages description of the pmt determinants an underlying premise of the pmt is that selfprotection is achieved through a process that includes the appraisal of a threat and an individuals perception of their ability to cope with that threat here we first describe our respondents perceptions of slowonset hazards in their area specifically soil and water salinization and channel siltation and then present results related to the factors influencing beliefs in their ability to selfmanage these gradual environmental changes over 60 of the respondents in three of our four study villages perceives that salinity of the water in the nearest tidal river or canal has increased in the 5 years prior to our study the only village where salinity is reported as high but unchanged over the previous 5 years is basantapur located in mathurespur union along the indiabangladesh border this is likely due to basantapurs location adjacent to a large tidal channel and lack of connection with freshwater river distributaries respondents here also described water scarce conditions they report that due to saline groundwater their drinking water comes solely from ponds and yearround cultivation of rice is not possible therefore rice crops are only grown during the rainy season several respondents ascribe the areas saline soil conditions to the vast conversion of land to saltwater shrimp farms that began in satkhira district in the 1980s another source of soil salinity is cyclones and strong coastal storms though the impact of storms is highly localized for example all respondents that we interviewed in munshiganj union described they were unable to produce crops for up to 3 years due to soil salinization following cyclone aila in 2009 yet interviewees in mathurespur union claimed they were not impacted by ailas storm surge and crop productivity was unaffected though the two unions are less than 30 km apart despite this spatial variability background salinity levels in southwest bangladesh are greatly enhanced in any area following a storm surge in addition to increased salinity infilling of tidal channels and canals by siltation is an ongoing phenomenon in this region of bangladesh according to wilson et al an estimated 600 km of formerly viable channels have been clogged with sediment and cut off from the channel network this is due to both natural and anthropogenic processes extensive poldering in the region has disconnected secondary channels from larger tidal rivers thus reducing the overall volume of water that can be transported through the system reduced channel network connectivity and diminished velocity of sedimentladen tides result in enhanced sedimentation within channels that over time emerges from the channel bed as new land or khashland specific to our study sites an average of 655 of respondents across three of four study villages report that siltation within the nearest tidal river or canal has increased however most inhabitants of dhankhali village report they are living on khashland that has been in place for decades one 42year old respondent described this i saw in my childhood that there was a slope from the land to the canal and the canal had higher depth of water than the agricultural lands but you cannot see that now the canal has been totally silted in but has a slight slope there from the lands the perception that channel siltation has not changed in the 5 years before our study implies that these former canals have all reached sedimentation capacity and have been under cultivation for years in addition to reduced network connectivity embankment sluice gates that are typically raised and lowered to allow monsoon floodwater to drain off cropland have become clogged with silt and are no longer functioning this effectually closes off internal drainage canals from the tidal channel network perpetuating siltation within perimeter channels these slowonset changes in the environment have impacted the economic state of the farmers in our study we hypothesized that those whose economic conditions have improved would be the least likely to migrate in our study sites only 125 reported that their wellbeing and economic standing had increased over the previous 5 years only 28 of respondents reported that their wellbeing and economic situation had decreased whereas most report stable conditions this suggests that although most of our respondents detect the slowonset environmental changes happening in their area they perceive these changes have not negatively impacted their ability to make a living mounting risk through stacked hazards may play a role in nonmigration decisions as the location of our study sites exposes them to hazards beyond siltation and salinization ie erosion waterlogging and cyclones we asked our respondents about their overall experiences with cumulative hazards our study shows that in the last 5 years the respondents in all villages faced an average of eight hazards with those in dhankahli reporting nine hazards and people in basantapur reporting six hazards we expect that respondents who have experienced fewer hazards would be more likely to remain in place being respected and responsible for the community influences perception at the individual level we found that almost onethird of respondents felt that they were not influential in communitylevel decisions that affect all villagers however almost half of all respondents were satisfied with the way that decisions affecting all community members in their village were made significant variations in the responses regarding both these extrinsic and intrinsic motivations across study villages were not found with regard to risktaking almost half of all respondents reported that it is challenging for them to take risks such as borrowing money to grow crops or shrimp planting a crop that they have not planted before or temporarily migrating for seasonal agricultural work in a place they had not worked before however over half of all respondents agreed that their family could survive changes in the environment that are affecting their livelihood sources it seems risk tolerance also influences future migration decisions an average of 355 of respondents within three of the four villages had moved their whole household temporarily to another place within their villages because of an environmental event except the people living in badurgacha only 14 of the respondents in their village were displaced due to an environmental event across all of our sites 645 of respondents had never been displaced even within their community due to an environmental event nonmigration decisions the respondents reported land inheritance and ownership as the prime reasons for their nonmigration decisions followed by the strength of their social networks and wealth and capital land inheritance and ownership used here means that respondents own the title to the land where they grow rice and other crops in badhurgacha and basantapur villages people prefer to be connected with their relatives and extended family members rather than be economically solvent in contrast results from mandartola village show that social network and wealth and capital strengths are equally important in nonmigration decisions the overall distribution of these reasons across the study sites are not statistically significant and therefore in this section we investigate the variations in the reasoning behind indicates the reference category of the independent variables others reasons of nonmigration is the reference category of the dependent variable respondents nonmigration decisions ie how and to what extent different variables influence nonmigration aspirations of the people in these communities determinants of nonmigration decisions we conducted a multinomial regression to explore the influence of different independent variables on reasons given for nonmigration decisions table 2 shows the results of the mnl our regression model indicates that age is an important indicator for those who claimed social network to be one of the primary and positively correlated reasons for remaining in place ie older people prefer to stay similarly respondents with more female members in the family reported both social network and economic strength as the reasons behind their nonmigration decisions respondents having less than 10 years of schooling were less likely to migrate compared to those with more than 10 years of schooling as expected respondents with a higher income chose economic strength as the primary reason behind their nonmigration decisions however no demographic factors showed significant influence on land inheritance and ownership as the driver of nonmigration land inheritance and ownership five pmt variables are shown to influence land inheritance and ownership reasons for nonmigration two environmental risk appraisal variables ie perceived severity and extrinsic motivation and three adaptation appraisal variables ie selfefficacy response efficacy and response cost those who possess land want to grow crops principally rice so that they can feed their family in this context salinization of soil or water can impact a respondents ability to produce crops on their land our model shows that a perceived decrease of salinity in the river and soil increases the selection of land inheritance and ownership as the main driver of nonmigration decisions if the salinity levels in the river and canal were to decrease by 1 compared to increasing by the same amount the multinomial logodds of selecting land inheritance and ownership for nonmigration would increase by 832 with all other variables in the model held constant the social acceptance of people in the villagelevel society of bangladesh is related to the amount of their landholdings and wealth individuals who are particularly involved in various social activities within a community are less likely to want to migrate in most cases they are the landlords and wealthy people of the community as societal acceptance in rural bangladesh is commonly inherited through landlordships known as zamindars in other words those who feel that they are influential in their community would prefer to remain in place thus extrinsic motivation plays a role in land inheritance and ownership determining a decision to remain in place our model results indicate that a 1 increase in the perception of not being influential compared to those who perceive they are always influential the multinomial logodds of selecting land inheritance and ownership relative to other reasons for nonmigration are expected to decrease by 47 with all other variables held constant in other words land inheritance and ownership contribute to being influential in the communitylevel decisionmaking process and therefore it promotes nonmigration all three adaptation appraisal variables ie response efficacy selfefficacy and response cost have significant influences on land inheritance and ownership as a driver of nonmigration decisions results show that increased risk tolerance reduces the selection of land inheritance and ownership as the primary reason for choosing to remain in place for example a 1 increase in the ability of a respondent to more easily take risks results in a 20 decrease in the multinomial logodds of selecting land inheritance and ownership as the primary reason behind a nonmigration decision similarly increased disagreement on survival despite changes in livelihood as a result of environmental change increases the selection of land inheritance and ownership as the primary reason behind opting to not migrate for example a 1 increase in the disagreement on the ability to survive despite threats to livelihoodmaking due to environmental changes results in a 50 decrease in the multinomial logodds of selecting land inheritance and ownership as the primary reason behind nonmigration again having any sort of migration experience reduces the chance of choosing land inheritance and ownership as the primary reason for opting to remain in place thus our result shows that respondents who had previously never migrated are almost five times more likely to choose land inheritance and ownership as the primary reason behind nonmigration than those who had migrated before however being affected by hazards does not have a significant influence on land inheritance and ownership for nonmigration decisions social network two pmt variables perceived severity of siltation and selfefficacy have significant relevance on opting for social network as the reason for a nonmigration decision the perceived severity of siltation variable relates to the siltation conditions in the nearest tidal river or canal our model shows that decreased siltation in the most adjacent river and canals increases the selection of social network as the primary reason for choosing to remain in place for example a 1 decrease of river or canal siltation results in a 924 increase in the multinomial logodds of selecting social network as the primary reason behind a nonmigration decision we interpret this to mean that decreasing siltation in nearby rivers or canals leads to increased fishing and water resourcebased economic opportunities at the local level which requires social connections and cooperation in order to be successful again our model shows that there is a significant causal relationship between the agreement of a respondents ability to survive despite threats to livelihoodmaking due to environmental changes and choosing social network as the primary reason for nonmigration our results also show that a 1 disagreement on the ability to survive despite threats to livelihoodmaking due to environmental changes results in 65 decrease in the multinomial logodds of selecting the chance of social network as the primary reason for nonmigration decisions in other words interdependency between people living in a community is the key to longterm nonmigration in addition to the pmt variables three demographic variables also showed significant influence on selecting social network as the reason for nonmigration the results indicate that a 1year increase in the respondents age results in a 54 increase in the chance of choosing social network as the reason for nonmigration in other words the older someone is the more likely they are to claim that their social network keeps them rooted to a place however the number of female members in the family also significantly influences social network as the primary motivator of a nonmigration decisions for example the results show that an increase of one female member in the family results in a 1799 increase in the multinomial logodds of selecting social network as a primary reason for nonmigration females are more likely than their male counter parts to maintain social networks implying that the number of female family members is an important indicator of whether the decision to stay or migrate is taken furthermore the cultural and religious orientation of bangladesh towards protecting females also influences the decision to migrate if a respondent has a comparatively high number of female family members they are likely to consider the safety and social security of these family members when deciding to migrate or relocate similarly the years of schooling of the respondent has a significant causal influence on selecting social network as the primary reason for nonmigration for example an individual with a minimum of 10 years of schooling is 26 less likely to choose social network as the primary reason for nonmigration than an illiterate individual economic strength two pmt variables ie perceived severity of siltation and extrinsic motivation have a significant causal relationship to selecting economic strength as a primary reason for nonmigration if siltation in the adjacent rivers and canals increases then the chance of choosing economic strength as the reason for nonmigration decreases for example a 1 increase in siltation in the adjacent rivers and canals results in a 65 decrease in the multinomial logodds of selecting the economic strength as the primary reason for nonmigration this indicates that increased siltation of the nearest rivers and canals may create water scarcity for crop production and thus affect the economic strength of the individual household with respect to an individuals extrinsic motivation here defined as the role an individual plays in the community decisionmaking process a 1 increase in the perception of not being influential when the community decisions are made results in a 43 decrease in the multinomial logodds of selecting economic strength as the reason for nonmigration in other words people who influence local decisions are also most likely to be economically solvent and therefore prefer to stay at the individual household level income plays a minor role in economic strength being the main reason for nonmigration a 1 increase in an individuals household income results in a 10 increase in the multinomial logodds of selecting economic strength as the reason for nonmigration in other words income solvency helps a respondent remain in place conversely the number of females in the household significantly influences the chance of economic strength being the primary reason for nonmigration adding one more female member to a household relative to a household with no female members results in a 2655 increase in the multinomial logodds of selecting economic strength as the reason behind a nonmigration decision this primarily indicates the economic importance of marriage education and social security of the girls in the family demanding dowry for a bride is common in rural communities in bangladesh so if a family has a daughter the parents should save moneyresources for arranging the marriage finally the education variable explains that people who have never gone to school relative to those who have more than 10 years of schooling are 766 less likely to choose economic strength as the primary reason for nonmigration that is our model confirms that the more educated a respondent is the more they claim that their economic strength is the reason for staying discussion the pmt offers several advantages to understanding how perceptions of both risk and an individuals capacity to respond to threat factors into nonmigration decisions first the pmt presents a single model for explaining the relative contributions that perceived risks and adaptive capacity indicators have on individuallevel decisions on migration there is no other analytical model that provides this for nonmigration decision analysis second the pmt also allows for the exploration of the reasons behind the reasoning ie it enables more indepth analyses by examining two levels of reasoning in this study the pmt allowed the identification of the individuallevel factors behind each specific reason given for not migrating the risk appraisal factors explain the importance of slowonset environmental changes in nonmigration decisions for example our results indicate that an individual landowner believes they can still produce crops if there is a perceived decrease in channel salinization therefore they will choose to remain in place in contrast the adaptation appraisal factors suggest that the individuallevel response efficacy selfefficacy and response costs have considerably more influence on future nonmigration decisions overall our results suggest there are three main reasons people at risk of slowonset hazards choose to remain in place rather than migrate land inheritance and ownership the strength of their social network and their personal influence and economic strength all three reasons are related to the concept of place attachment although settlement history is also connected with land ownership assets and strength of social and economic conditions we do not see a significant association between settlement history and nonmigration this may be related to site selection criteria in that we selected sites relative to their proximity to channels and their landuse history several changes in socioeconomic conditions have been reported due to conversion from rice to shrimp and thereafter these respondents have chosen to remain in place the most notable result is the influence of land inheritance and ownership on nonmigration decisions which is the only outcome represented equally across all demographic categories the causal relationships between the variables used in the pmt model are demonstrated in fig 4 in this causal network migration and nonmigration are outcomes of the level of satisfaction of living in a community at risk of slowonset environmental hazards ie the intrinsic reward governs the decision to migrate or to stay both nonmigration and migration contribute to local livelihood conditions in the case of nonmigration people who stay in the village exploit nearby natural resources or seek workforhire near their village eg collecting shrimp fries from the river to sell at the market day labouring for cash or cultivating vegetables in village courtyards to sell during the rainy season when soil salinity is decreased individuals who migrate particularly seasonal migrants who go to cities or internationally to find work do not depend on local resources but support village livelihoods through the sending of remittances economic conditions which is a perceived vulnerability factor of our pmt model influence the ability of an individual to selfmanage future environmentallyrelated changes in their livelihood the pmt model refers to this as selfefficacy and effects the satisfaction of living in a place similarly economic conditions frame the social prestige and public image of an individual household and therefore this acts as an extrinsic motivation that influences the overall satisfaction of living in a place the experience of being affected by natural hazards is not significant for any of the three reasons for nonmigration this suggests environmental hazards do not necessarily motivate nonmigration decisions but may contribute to the experience of migration people who have had experience with both past environmental hazards and migration perceive that they are capable of surviving future hazards demonstrating selfefficacy we found that extrinsic motivation ie motivation driven by external rewards such as positive social status recognition for good work or political affiliation has a significant influence on nonmigration choices perceived or actual changes in siltation and salinity in the nearest tidal rivers and canals also have a significant influence on the decision to stay home as these impact agriculture and fisheries production in the study villages future studies can expand on this work by including the effects of environmental recovery lag times on nonmigration decisions that is factoring in the time that it takes for land to be suitable for crop production following salinization this would enhance our understanding of the thresholds between nonmigration and migration in rural hazardprone coastal environments the study has a few constraints first the sample size of the study was relatively small and geographically constrained to coastal bangladesh this may raise questions regarding the broad representativeness of the findings particularly with regard to statistical treatments as we applied a purposive multistage sampling approach that considered different geographical and sociopolitical attributes in selecting our study villages our claims may be representative for coastal bangladesh more broadly further empirical research using a larger sample size collected from a wider range of geographical settings is needed to evaluate and validate the contribution of pmt to understanding voluntary nonmigration decisions however to our knowledge this is the first study to demonstrate that land inheritance and ownership social status and network connectivity play a role in an individuals decision to remain in place despite risks posed by gradual environmental change second a gender bias is reflected in our very small sample number of female respondents and therefore obscures household power dynamics and the role of females in decisionmaking however our findings are representative for bangladesh where rural communities are culturally and socially patriarchal finally a disadvantage of employing the pmt is that it does not consider the impact of social norms arising from eg religious beliefs and therefore continued work will be needed to understand the role of informal institutions and cultural influences beyond which a nonmigration decision becomes a migration decision that is at what level does environmental risk become so great that land ownership and social status are overridden and no longer provide an individual with a sense of selfefficacy the results provide insight to the importance of individuallevel social influence on the formation of novel communitylevel social norms related to environmental migration as sea level continues to rise and dam and embankment building continues in watersheds and coastal zones salinization and shifts in sediment dispersal will become more widespread in lowlying coastal areas this work gives insight on how individuals currently make the decision to remain in place despite perceptible and potentially livelihoodthreatening slowonset hazards and provides a baseline for examining how decisionmaking evolves in response to environmental change localscale adaptive capacity building and planned relocation efforts in hazardprone coastal areas will be most effective when the relationship between constantly evolving environmental change and behavioural decisions is better understood

nonmigration is an adaptive strategy that has received little attention in environmental migration studies we explore the leveraging factors of nonmigration decisions of communities at risk in coastal bangladesh where exposure to both rapidand slowonset natural disasters is high we apply the protection motivation theory pmt to empirical data and assess how threat perception and coping appraisal influences migration decisions in farming communities suffering from salinization of cropland this study consists of data collected through quantitative household surveys n 200 and semistructured interviews from four villages in southwest coastal bangladesh results indicate that most respondents are unwilling to migrate despite better economic conditions and reduced environmental risk in other locations land ownership social connectedness and household economic strength are the strongest predictors of nonmigration decisions this study is the first to use the pmt to understand migrationrelated behaviour and the findings are relevant for policy planning in vulnerable regions where exposure to climaterelated risks is high but populations are choosing to remain in place

introduction sankhu lies in the northeast of the kathmandu valley and it was the main route to tibet in most of the ancient medial and modern nepal and till the early 1960s before the construction of the kodari highway from kathmandubhaktapurbanepa and khasa tibet sankhu is a traditional settlement of kathmandu valley dating back to the ancient lichchhavi period in the history of nepal which flourished due to its strategic location in the trade route to tibet sankhu town is a culturally rich town with an inhabiting newar community and is the place of rich heritage there are many public and private heritages and very historical and valuable temples such as bajrayogini mandir in that area most of the temples and public buildings were also severely damaged by the earthquake apart from that many government buildings such as schools and government offices have also been collapsed and damaged most of the destroyed and damaged houses were constructed with brick and mud joints which were built 70 to 80 years ago though people in sankhu as well as outsiders still believe that sankhu contains a thousand houses in 1997 it appeared that there were only 789 on a total population of 53401 the data collected was only inside the historical boundary of sankhu town the survey did not count the boundary outsides sankhu the recent data of municipality shows that 2545 households are comprising 11825 populations in sankhu a strong earthquake of magnitude 78 richter having an epicenter in barpak a mountain village in gorkha district nepal hit the country on april 25 2015 the quake was followed by more than several hundreds of aftershocks and another huge earthquake of magnitude 68 richter having an epicenter in the sindhupalchok district hit nepal on may 12 2016 causing more death injury and damages as a result 8790 people died and more than 22300 people were injured pdna 2015 accessed the findings of the immediate impacts of the 2015 earthquake in livelihoods means deaths and injuries there was huge physical loss was the primary impacts direct impacts on physical infrastructure showing the loss of npr 530 million estimated damage of npr 5300 million was seen leading to a total loss of npr 5830 million there was a total loss of npr 5830 million subject to the case of temples in remote areas npr 900 million was damaged with a complete loss of npr 90 million summing to a total loss of npr 990 million studies have been conducted to assess the impact of devastating earthquakes in nepal by both native and foreign scholars yet few studies are revealing the impact of the earthquake in sankhu the traditional town of kathmandu valley sankhu witnessed both out and inmigration after the devastating earthquake damage assessment was carried out by a technical team of the engineering college several traditional buildings and monuments in the kathmandu valley were collapsed to the ground completely changing the built form of several traditional towns such as bungamati khokana and lubhu in this regard traditional town sankhu is also not an exception earthquakeinduced migration and internal movement is a recent phenomenon in the country after the great disaster hit the country on april 25 2015 the magnitude of the disaster is not limited only to the country itself but it had affected the country too most parts of india and china too oxford dictionary refers to disaster as a sudden accident or a natural catastrophe that causes great damage or loss of life migration as the movement of people to a new area or country to find work or better living conditions the international organization for migration defines displacement as the concept of forced movement and a forced migrant is one who migrates to escape conflict repression natural and humanmade disasters ecological degradation or other situations that endanger his lives freedom or livelihood migration after displacement is a final decision for the earthquakeaffected population for better livelihoods livelihood is a means of subsistence comprising a complex and diverse set of economic social and physical strategies a rural livelihood comprises one or more often several activities which variously provide food cash and other goods to satisfy a wide variety of human needs this impact implies that the impact on stress reactions of additional traumatic experiences at the individual level is dampened when the community as a whole has been heavily damaged and likewise that the impact of more intensive community destruction is dampened for individuals who experienced high levels of individual trauma disaster impacts may include loss of life injury disease and other negative effects on human physical mental and social wellbeing together with damage to property destruction of assets loss of services social and economic disruption and environmental degradation the potential disaster losses in lives health status livelihoods assets and services which could occur to a particular community or a society over some specified future period one of icimods studyconcluded that geohazards induced by the 2015 gorkha earthquake were landslides river channel constriction and damming and avalanches with debris flow and airburst bandita sijapati et al a research work published in migration and resilience the research was carried out in the districts sindhupalchok kavre dhading and kathmandu have shown the linkage between earthquake and migration displacementthe study revealed more of those households with male migrants reported that their absence harmed their families during and immediately after the earthquake central department of population studies cdps carried out a study about the demographic and social impact of the gorkha earthquake drawing the sample from the 14 most earthquakeaffected districts the fieldwork was carried out from 20 november 15 december 2015 and a total of 3000 households were surveyed key findings of the study were the marital status of 88 household members changed following the earthquake a majority of married women turned to be either widow or divorcedseparated following the earthquake two in five members of the entire households surveyed had changed occupation from agriculture to wage labors household works and others nearly 3 percent of the household members reported suffering from psychosocial problems more than 7 of the households reported that at least one member of their family had migrated for foreign employment during the last year before the earthquake and had not returned even once after the earthquake the increasing trend of labor migration overseas in search of better work after the earthquake was highlighted by fgd participants from nuwakot sindhuli kathmandu and sindhupalchok in this context the key aim of this study was to identify the reasons behind in and outmigration infrom the location to examine the status of migrants in sankhu and cultural change and to assess the impact of migration on livelihood after displacement due to the 2015 earthquake sankhu sankharapur was selected based on highly affected by the recent earthquake in the country which also have resulted in high mobility of the population data and methods the field study in sankhu was conducted during the 2075 bs year in the field the researcher observed the damage caused by the earthquake conducted focus group discussion with the affected communitiesthe study includes a descriptive research design it is exploratory as it attempts to explore the livelihood strategies of the migrants a rapid assessment observation kii fgd and case studies were undertaken over the period from june 1229 2018 six research team members were deployed to three sites in the study area for kii and fgd and two for case study along with earthquakeaffected people identification in each location to guide fgdkii participants all three teams two members in each team conducted a short survey to capture key elements of the migration condition due to the devastating earthquake and how that might have affected households and their livelihoods the teams interviewed people using a checklist that covered the general effect of the earthquake and the immediate impact of the earthquake at the household level to investigate 34 major and minor cultural practices that were doing in the past around a year each member who participated in the focus group were asked individually about the practices 12 participants in a group first and 11 participants in group second were asked regarding the practices basic information of the research was collected through the observation and available documents from the municipalitythe research identified three categories of respondents however all three were the victims of the earthquake the first category is identified as a victim who was living in sankhu at an original house the second category is victims who were living in sankhu but were displaced from the place of origin to the other communities within sankhu the third category is identified as a victim of the earthquake who migrated or displaced out of the study area the research team identified respondents for key informants interviews the research team selected respondents based on information collected from the municipality office and nepal police based on the information 9 respondents from three different locations were selected three respondents were selected in each category the research team selected further five people for a case study and two women groups for focus group discussion results during the survey we also collected the data from local government agencies such as the municipality wards according to the sankharapur municipality record during the earthquake of april and may 2015 a total of 112 people died and 179 people were injured in sankharapur municipality in terms of property loss a total of 694 houses collapsed and 961 houses partially damaged only some of the houses which are recently built with rcc structures are safe for living as sankhu town is densely populated compared to other areas of the municipality it suffered much in sankhu town a total of 40 people died and 52 people injured inmigration after the earthquake people from different places are also coming to sankhu and living in the surrounding of sankhu and they are involving in different wage works small business few people from solukhumbu have constructed houses at the southwest corner of the sankhu except few majorities of the individuals working in daily wages are from other districts such as sindhupalchok nuwakot and dolakha the trend of immigration from outside districts for labor works has increased after the earthquake this scenario created a heterogeneous society in the community on one hand people are coming from outside to sankhu and in another handsankhu people are moving outside the sankhu especially upper midlevel people from the origin are moving outside either for seeking jobs or for business and most of the lower midlevel population are residing in sankhu seeking opportunities within the sankhu outmigration after the earthquake according to the participants of fgds it revealed that the affected families are moving to and from different places surrounding the sankhu its vicinity and displacement occurred finally some are planning to migrate and some are migrated outsides the sankhu displacement found first step mobility before they decide to migrate the volume of migration from sankhu is towards the kathmandu city where they are either already a place to live or planning to live there fgd members argued that many going to kathmandu will not return as they already have settled business or house in kathmandu analyzing the fgd and kii information several reasons evolved for outmigration from sankhu due tothe earthquake after the earthquakes people have lost their houses and properties people have no place to live in their place of origin home people have to look at alternative places for immediate living accommodations people have no place to live in their original home aslocal municipality reported that more than 90 of houses damagedcollapsed in sankhu people have been looking for the alternative place for living our rapid assessment at eight clusters of sankhu have shown following statics our field survey reveals during the survey people are still living in the area of their place of origin in sankhu some in tents or cgi tin trust made sheds some in the repaired collapsed house people are looking for better livelihood opportunities our interview with a headmaster of higher secondary school says that most of the youths from sankhu are seeking optional opportunities outsides the sankhu and abroad too few youths those who have linkage abroad have already gone to gulf for employment some are on pipeline and some are processing for passport and visa similarly our kii explored similar issues like youth attracted for external migration for foreign employment as their houses collapsed the middle economic status of sankhu engaged in small business and services have lost their house and business locations they have been displaced internally and some moved to the surrounding communities such as at indrayani jorpati and kathmandu city living status of displaced people in sankhu our observation during the survey we found that worst living environment of internally displaced people of sankhu among every five houses in one house some of the family members are sick leaching water from the roof damp floors where they are sleeping single room for a whole family the kitchen at the same room little space available for storing grainsagriculture products and other foodstuff hygiene sanitationdrinking water temporary toilets nearby the kitchen an observation regarding the environment for education no conducive environment for reading to kids at temporary living places no recreation center available in surrounding for children impact of migration on the livelihood of the people of the location due to inmigrants as well as outmigration change in community structure from homogeneous group to heterogeneous group conflict situation families who moved to their own relatives house is also facing the problem of personal conflict after living together perceives destination as facilitative of socioeconomic mobility relative to an origin long term problem for outmigration people who are living in a joint family some family members left sankhu those who live in the house have no land certificate so they are not able to renovate the collapsed houses and have pushed them to migrate outsides the origin data from the land revenue office reveals that 75percent of land owned by sankhu origin has been sold one can observe barren land here and there in the vicinity of sankhu due to changesin land ownership which has a huge negative impact on agriculture production following factors have encouraging sankhu people to sell their agricultural land as an immediate solution for solving the recently emerged problem due to earthquake and which fuels to push them to migrate outsides the origin recently developed semiurban characteristics of the rural people have diluted the social networking discontinuation dissolution of social institutions such as guthrie parma paincho rituals festivals became a negative catalytic agent to liquefy traditional sustainable social harmony this also has a negative implication on of cultural activities impacts on infrastructure and livelihoods people have no place to live in their original home more than 90 of houses damagedcollapsed affected families are not in the position to renovate reconstruct the damagedcollapsed houses as they have been waiting for grants from the government and other agencies they have been living in a joint family and have no individual land registration certificate it also hampering them for reconstructing houses people have to look for better opportunities for livelihood and safe living place people could not continue their original business as they have no place left lost the equipment money materials and could not earn as before because of less mobility of people as well as people engaged in agriculture work has no land as they have used their land for temporary settlement or sold for meeting daily needs or for collecting money for constructing new houses or starting new business people feared from the earthquake and aftershocks have chosen safer place to live and people look for a safer environment for the study of their children health care as well as the recent change of center place in sankhu proved by members of business enterprises increasing outsides the sankhu than in sankhu town which was a historic business place during the surveythe researcher counted the business enterprises in sankhu before and after the earthquake the result shows the numbers decreased to 420 from 500 the numbers of business enterprises inside sankhu town was found half only showing displacement of centre place of sankhu change in cultural practices due to displacement as people have shifted or displaced from their original place of living and have settled in one way or another they have to live with some new neighbors in the new environment so the community structure changed from a homogeneous group to heterogeneous group we observed distortion of their traditional practices such as mela parva less participation in jatra and perma and except major festivals other few are following minor2 festivals events and except the siguthi only a few people meeting for guthis such as guthis related to minor jatra krishna jatra and ganesh jatra discussion we observed changes in cultural practices due to the displacement of sankhu people in sankhu after the earthquake people have fair about the loss of identity due to a loss in cultural practices in this regards our discussion with the focus group discussion researcher investigated 34 major and minor cultural practices were doing in the past year our finding reveals that in the past before the recent earthquake a cent percent population of the sankhu were continuing 34 ritual events after the earthquake people are continuing these events but the percentage of the population who continuing has been decreased by ten percent most of the displaced people stopped celebrating minor festivals at a rate of decreasing 10 to 60 percent but 99 percent of the population is following the major festivals such as dashin main bajrayogini jattra and tihar an interview with the priest of the sankhu says that most of the people are not performing shraddha too before the earthquake i have to visit at least 10 house in this summer season but this year hardly one two houses per day invite me to perform shraddha last year we three members from house need devote to cover those events in a day everyday the researcher also shortly interviewed with a buddhist priest and astrologist says that i have advised to not necessary to follow all kind of funeral process who was died due to earthquake as there is no space to perform all kind of process still houses are not built people are in the temporary stay therefore cannot perform complete processes the priest also responsible for the bajrayogini festivals he added that we are also not able to lunch all the process during bajrayogini jatra too because of less participation in the jattra and summarized the process in the past people invite us to assist us in different ritual installations in and around a year but after the earthquake very few invite us therefore our income drastically slumped this year as a priest nobody requesting for attaining the ceremonies like birthday birth rituals marriage and death rituals major sources of income and those who can pay for the celebration process are not residing in sankhu nowadays damage of livelihoods and miserable living conditions nonmigrants of sankhu were also inquired about their living conditions and also observed by the researcher their living condition was very much miserable and risky for health hazards there was very limited space for accommodation in tents and trust made temporary sheds they have to live in crowded poor sanitation facilities having no clean drinking water they drink water by leaching from the roof people sleep on a damp floor there was a single room for a whole family there was no separate kitchen people live in places unprotected from insects and snakes poisonous insects schools were also damaged and there was a poor environment in school for children similarly people could not continue their original business as they have no place left lost the equipment money materials they could not earn as before because of less mobility of people and they could not find a job and they have to take risks of adopting new occupation people also feel threatened as they have to with unfamiliar people the inmigrants as well as the relief workers as people have moved or been displaced from their place of origin and have settled in one way or another they have to live with some new neighbors in the new environment so the community structure changed from homogeneous group to heterogeneous group some of the key informants also reported that some households have sold their lands to cope with the situation most of them who sold land and willing to sell have no plan of making investments for better income than to meet the current expenditure for livelihoods because of less land as some land has been used for temporary shelter others sold for collecting money for reconstruction of house and other needs it was also difficult in constructing even the temporary shelter and in some cases the conflict in settling boundaries of land was also evident family relations have also been changed due to the earthquake families who moved to their own relatives house are also facing the problem of personal conflict after living together people who were living in a joint family some family members left sankhu while others left in sankhu those who were living in the house had no land certificate so they could not able to renovate the collapsed houses timely conclusion from the above discussion it can be concluded that migration took place in short distances after several displacements which were the immediate impacts of the 2015 earthquakethe 2015 earthquake has an immediate impact on infrastructure private buildings public buildingscultural heritage and the health of the families in the affected communities negatively finallyour findings reveal that it has an impact on infrastructure occupation education health a culture which are the means of livelihoods the results of this study conclude that in postdisaster migration of sankhu the volume of displacement within the sankhu is higher than the volume of migration outsides to the sankhu and proved that migration is selective in the study area similar to the example in sankhu shows priority basis migration with the selection of opportunity of earning place either at the vicinity of sankhu or kathmandu city in the field it was also evident that some shorts of conflict within the family and neighbors also occurred whether migration is permanent or temporary one has always been a traditional response or survival strategy of people confronting the prospect impact or aftermath of the disasters our findings from sankhu reveal that some strategic towns like sankhu experienced both outmigration and inmigration in the study area migration took place fromrural to urban areas even in the shortrun there is no employment opportunityas well as the recent change of center place in sankhu proved by numbers of business enterprises increasing surrounding the sankhu than in the sankhu town during the surveythe researcher counted the business enterprises in sankhu before and after the earthquake the result shows the numbers decreased to 420 from 500 it was found that when rapid onset disasters occur people often leave the affected area to avoid physical harm or loss of life cultural practices are found declining for respecting the people who are staying in sankhu struggling with difficulties and for the people who love the ancestral place of sankhu providing greater relief reconstruction managing loans and prioritization of reconstruction are urgent the role of the government is twofold first to help in the reconstruction of an infrastructure that can help modernize the economy and second to introduce development strategies that rely on human capital

the central objective of this study was to explore to assess the immediate impact of the 2015 earthquake on livelihood limited studies were carried out after the 2015 earthquake except for a few notes no academic research was available till the period of this research done about sankhu here the researcher himself from sankhu tried to explore the postearthquake impacts of migration a historic town in sankhu this study was based on the qualitative research methodology and revealed immigration started in the community that has a lot of impact on culture economy and infrastructure in the community historically since the panchayat regime there was no trend of immigration the purpose of outmigration was for education to business on one hand the 2015 earthquake forced them to migrate from sankhu and on another hand the implication 2015 earthquake on migration forced people to change their residences and different parameters of livelihoods the results of this study conclude that volume of migration within the sankhu is higher than the volume of migration outsides to the sankhu short distance migration preferred after the 2015 earthquake the immediate impact of the 2015 earthquake was on infrastructure occupation education health the culture which are the means of livelihood several displacements was the first step of the impact of the 2015 earthquake before migration for better livelihoods we observed that migration is selective our study reveals that priority basis migration with the selection of opportunity of earning place either at the vicinity of sankhu or kathmandu city as well as the recent change of center place in sankhu proved by members of business enterprises increasing surrounding the sankhu than sankhu town inside which was a historic business place the people who are staying in sankhu struggling with difficulties for better livelihoods destroyed

introduction this study explores everyday photographic practice and how various forces from technological affordances to demographics and varying levels of visual literacy shape and inform how ordinary people use smartphone cameras and affect the images they make estimates suggest that camera phones accounted for 925 percent of all photographsclose to 2 trillionmade in 2023 yet the way smartphone cameras are used can vary by region and by cultural context for example some estimates suggest that people in north america take more photos than their european introduces affordances theory as the analytical framework that will guide the image analysis we later conduct key technological developments in the evolution of photography the first cameras were limited by todays standards and required long exposure times from minutes up to an hour that rendered capturing motion impossible and made portraiture impractical for much of its early history photography was also not affordable for the masses nor was it a speedy or particularly easy activity the speed aspect in particular changed with the invention of polaroid instant photography in 1947 which davenport calls a truly revolutionary system the oldest participants in our sample were born in the 1950s so we pay particular attention in this section with tracing the development of key photographic milestones from the 1950s to the present these include the first camera with aperture priority mode in 1956 the introduction of the first pointandshoot cameras and the first cameras with autofocus in 1963 the first fully automatic camera in 1974 the invention of the first portable digital camera in 1975 the first dslr cameras in 1986 the first camera phones in 2000 the first iphone and the birth of smartphones in 2007 and the first smartphones with multiple cameras within the last decade in 2014 even though the first digital camera was invented in the 1970 the device wasnt affordable enough light enough or capable of producing photographs of sufficient resolution for the technology to be more widely adopted until the late 1990s and early 2000s indeed digital cameras didnt outsell film cameras until 2003 these technological developments over the past 70 years enabled new cultural practices and uses which affected what was photographed and how for example even though cameras gradually became lighter and smaller over time that they were standalone devices that had to be brought in addition to other personal effects meant that they werent commonly carried around except for certain occasions such as travel ceremonies or special events when cameras became coupled to phones in 2000 it revolutionised how photography was used and what became fair game for documenting having a camera with oneself at practically all times led to practices such as documenting ones meals and documenting the banal as well as the special since smartphones overtook standalone cameras in the 2010s in terms of popularity recent developments have focused on the addition and refinement of lenses and accompanying camera sensors these improvements mean that more photography can be undertaken at night or in lowlight environments they also result in more processing and automation that has the potential to reduce the photographers creative control and influence on how the scene is rendered personal and everyday uses of photography previous studies on smartphone photography have identified two main categories of images those that are affective on one hand and those that are functional on the other affective photos are those that are taken for personal reflection to share with someone who is absent or to enhance a shared experience functional photos conversely exist as reminders to self or others of images that support a mutual task smartphone photography is often different than imagery produced by standalone cameras in its degree of individualisation and its mundane everyday nature various age cohorts have faced uneven research attention in relation to their digital photography use much of the relatively small body of research that focuses on everyday digital photography practices uses young adults as its sample population because of increased ethical challenges recruitment difficulties and varying digital literacies research on older adults practices has been limited some of these same issues also exist for the other end of the age spectrum the research that has been undertaken on young adults smartphone photography use has suggested age is a relevant factor when it concerns the photos compositional content this research also suggested that millennials had limited artistic expectations of smartphone cameras found selfies to be pedestrian and that they rarely discussed photographic composition early research that has focused on the content of everyday smartphone photography has tended to focus on aesthetics through filter effects at the same time this research acknowledges that camera phone aesthetics are liquid and constantly in flux while research on the motivations for using smartphone photography has received the most research attention what is missing is a granular look at the visual practices evident through the smartphone photos ordinary individuals make in their daytoday lives along with this the present study also responds to calls by scholars such as schreiber for the need to broaden the research scope beyond a nearexclusive focus on young adults smartphone photography use affordances theory this study uses the media affordances concept as its theoretical framework at its most basic affordance theory refers to different action potentials offered by an environment technology or other entity affordance theory arose as a middle ground between technological determinism and social constructivism strong et al defines affordances as the potential for behaviour associated with achieving an immediate concrete outcome and arising from the relation between an artefact and a goaloriented actor or actors in offering this definition strong and colleagues propose a focus not just on the artefact but also on the relation between it and the user affordances can be positive or negative the relational nature of the affordance concept necessitates a focus not just on the technology but also the users of that technology and the broader social cultural and environmental landscapes they find themselves in in the context of this study an example of an affordance is the portrait mode in an iphones camera app that applies a digital effect around the background of a subject to simulate a shallow depth of field some conceptualisations of media affordances theory narrowly understand an affordance primarily as what functions or uses the platform or equipment enables our constraints this narrow view however limits in some ways the agency of the user and doesnt fully account for environmental attributes or personal decisions that also affect the user experience and in this case the resulting photos that are made examples of these individual or environmental attributes include the composition the user decides on or the direction and quality of the light in the scene which can markedly affect the photos made even though the user has potentially limited control of the lighting in a scene beyond adjusting the overall exposure in the camera app as such this study extends the way media affordances theory is typically applied to include not only equipment or software design but also the equipment and softwareindependent decisions a user makes and the environmental attributes of the scene that affect the photos made the present study responds to schreibers call for additional research on the affordances of digital photography specifically she argues digital photography clearly affords new possibilities … but how those affordances are used by whom and in which contexts … remains to be empirically investigated this is a concern also echoed by peters and allan these researchers participants cited smartphones portability alwayswithinreach status and easeofuse as chief technological affordances by the same token they listed insufficient resolution inadequate storage poor zoom quality and poor performance at night or in low light as constraining factors of their smartphone cameras affordances yet these enabling and constraining factors are a product of a specific time so it is worthwhile to investigate this question periodically so as to see how technological developments are altering what participants at a particular time perceive are enabling or constraining certain uses given the abovenoted gaps about age disparities in researching digital media use stillnascent understandings of how digital photography affordances are manifesting themselves in the contemporary climate and how perceptionproductioneditingandinterpretation tend to be studied in a piecemeal rather than integrated fashion the study proposes the following three research questions rq1 what types of images do australians capture using smartphone cameras rq2 what are the specific visual language evidenced in the smartphone photos made by generationally distinct australians rq3 how do smartphone camera users in australia explain their use of these devices to create photos methods this study adopts a qualitative research methodology that includes data donations by 30 participants an 11point visual analysis of the more than 1200 images they donated that is informed by media affordances theory and complementary followup interviews sampling considerations and participant recruitment the study recruited those aged 1364 who were living in australia and had a smartphone that they use to take photos on in determining this age range we drew on the australian bureau of statisticss groupings to arrive at this upper age range our proposed age range is already quite broad and represents at least three generationally distinct age ranges who have likely grown up in distinct visual cultures that inform their smartphone photography practices adding in a fourth category for those 65 and older would add to the complexity of the study beyond our current capacity as such we focus with this initial project on teenagers and those in early and middle and late adulthood only after obtaining institutional ethics approval we created a callout through personal professional networks to recruit potential participants we also asked participants to identify others in their own networks who are eligible for the study in this way we used a mix of purposive and snowball sampling methods to recruit participants who met the studys inclusion criteria in all 30 participants agreed to participate in the data donation phase and 23 participants followed through with an indepth interview to contextualise their photographic behaviour and shed light on the aspects they perceive shape their ways of seeing data collection and analysis after being provided with the studys informed consent materials and expressing their desire to participate participants were provided with a unique link to a private online folder that they used to share with the research team the images they had already made on their smartphones during a consistent twoweek period before learning about the study importantly asking for images already made before learning about the study allowed us to to avoid participants monitoring or changing their photographic behaviour also important to note is that we promised participants that images they provided would only be seen by the research team and not appear in any public formats which helped mitigate any privacy concerns the participants images were then subjected to an 11point visual analysis systematically recorded in an excel spreadsheet that includes the following aspects � whether the frontor rearfacing camera was used � the photos orientation � whether the images metadata indicates that any filters or other camera effects have been used or applied � whether the image is blurry or outoffocus � the cameratosubject distance � the photos representational content � compositional placement context � the horizontal angle � the vertical angle � the type of light source present � the directionality of the light sources considering definitions of visual literacy such as the ability to view images with a certain level of comprehension that privilege context purpose and audience it would not be sufficient for the researchers alone to try and read the images and understand their meaning in isolation from their creators viewpoints as such in addition to studying the images themselves the researchers also interviewed the images creators so as to understand context purpose and audience from their perspectives and to ensure that the researchers understandings of their photographic practices and visual literacies were directly informed by participants insights interviews averaged 60 minutes and discussed whether the participant had any prior photographic or art training in their background how much experience if any they have with standalone cameras their perceptions of how different age cohorts use smartphone cameras their awareness of composition their specific photographic practices and what they regard as sources of inspiration or influence for their photographic practices audio from the interviews was transcribed and was coded in nvivo using the constant comparative method for each of the three generationally distinct groups findings overall 30 participants donated for analysis 1253 photographs taken over a twoweek period the range was from 6201 across the entire sample women and girls made an average of five photos more than men and boys when relevant insights from the followup interviews are presented alongside the image analysis findings to further contextualise them who or what was photographed the first research question asked what or who participants photographed during a consistent twoweek period results will be presented for the entire sample first and then will be followed by gender and age breakdowns findings for gender and age are reported as averages relative to the overall number of participants to allow for comparison participants photographed people most of all and this was followed by photos of objects the built or natural environment and animals girls and women made up 6333 of the sample but made 7384 of the photos of people while boys and men made up 3666 of the sample but were responsible for 2615 of the photos of people boys and men photographed objects in an aboveaverage frequency relative to their share of the sample while girls and women photographed objects in a belowaverage frequency relative to their share boys and men photographed the built or natural landscape slightly below their share of the sample while girls and women photographed the built or natural landscape slightly above their share of the sample boys and men and girls and women photographed animals in nearly equal proportions relative to their sample size age life circumstances and cultural practices the participants said influenced who or what they photographed with their smartphones teenagers for example repeatedly described their choice of subject matter in much wider terms than the older age groups they said they used their smartphones to photograph random things this view is exemplified by one teenage participant who said with my phone i just take photos of anything the younger generation takes more careless photos with younger people its more spontaneous like spray paint on the wall graffiti we might take pictures of that but i think the older generation they wouldnt really see it as i would maybe theyd just dismiss it as oh its there you know but they wouldnt photograph it as the generations get older they take more planned photos they wouldnt take a lot of random photos participants in the older age brackets frequently reported using their smartphones for photography during work situations or for other functional purposes and described their photographic practices as a bit boring actually one participant from the middle age bracket put it like this i often take photos of info i want to save or of clients work when i want to then email it to myself to put on the computer i feel like ive gotten a little slack on socially taking photos of friends … but in the daytoday i feel like i use it very practically now for basically work grabbing a photo to upload it online somewhere in terms of frequency of use older age brackets uniformly said their photographic activity was driven by weekly cycles and that they usually took more photographs on the weekends compared to during the work week for the younger age bracket the frequency was peopleor contextspecific some participants spoke about only photographing when doing something exciting or going somewhere nice while others spoke about photographing more when with friends than when alone regarding age teenage participants said that they perceived older people took fewer photos because they either perceived there is not much to do or that for the participants who had grown up in the film era with finite exposures that their photographic behaviour was still affected by a mindset of conservatism regarding how often photography should be used and for which purposes the data however did not bear out these assumptions regarding frequency of photographic activity 1 the middle age bracket made the most photos followed by the oldest age bracket and the youngest age bracket in terms of who or what each age bracket photographed by age the middle age bracket photographed people aboveaverage relative to their sample share while teenagers and older adults photographed people belowaverage relative to theirs when photographing objects the teenage participants photographed this category in about equal proportion to their sample share while the middle bracket photographed this category belowaverage and the older bracket photographed this category above average when photographing the built or natural environment teenagers photographed this category in a belowaverage frequency relative to their share while the middle and older brackets photographed this category with aboveaverage frequency relative to their shares when photographing the last category animals teenagers photographed this category in belowaverage frequencies relative to their sample share while middleaged and older adults photographed this category in aboveaverage frequencies relative to their shares imagelevel features and technological affordances the studys second question explored through a multifaceted analysis specific features and attributes of the images participants made on their smartphones to reveal insights about everyday photographic practices among different age groups and genders due to space limitations only the most dominant practice is reported for each category as it relates to age and gender frontor rearcamera use the first attribute was whether the smartphones front or rear camera was used across the sample the rear camera was used most frequently followed by the front camera and 23 of photographs that werent able to be classified boys and men used the front camera less often than did girls and women by age teenagers and older adults were underrepresented relative to their sample size in the share of the selfies while the middle age bracket was overrepresented relative to its sample share several of the older participants said in the followup interviews that they perceived younger people made selfies constantly however selfies were only mentioned by a single participant when responding to the openended prompt how do people in your age cohort use their smartphone cameras as such as exemplified both by the image analysis and the accompanying followup interviews the perception that youth are selfieobsessed might be overstated photo orientation the second attribute concerned whether the participant used a square horizontal or vertical aspect ratio when making photographs across the whole sample the vertical orientation was most dominant with 6751 of all photographs this was followed by the horizontal aspect ratio and the square aspect ratio despite only making up 3666 of the sample boys and men were responsible for 708 of the vertical photos in the sample by age teenagers and older adults were underrepresented in their use of the vertical orientation relative to their sample share while the middle bracket was overrepresented relative to its sample share the younger and middle age brackets said they adopted a vertical orientation because of its ease convenience and quickness compared to using a horizontal orientation while the older age bracket frequently mentioned holding the phone vertically was more comfortable a number of participants across the younger and middle age brackets also noted how the portrait design of many mobile apps including snapchat and instagramrather than the content they were photographingalso affected their decision to photograph in portrait mode blurry or outoffocus photos the third attribute concerned the proportion of blurry or outoffocus photos about 83 of all the images in the sample were blurry or out of focus the proportion between men and boys and women and girls was almost exactly equal by age teenagers and the middle bracket were underrepresented in their proportion of blurry or outoffocus photos compared to older people who accounted for 552 of these photos light the fourth attribute concerned which type of light sources were present in participants photographs natural lighting was the most popular with 618 of the sample this was followed by artificial ambient lighting mixed lighting and artificial flash by gender girls and women were overrepresented in their use of natural lighting while boys and men comprised the remaining 30 and were underrepresented in this type of light relative to their sample size by age middleaged adults were overrepresented with this type of light relative to their sample while teenagers and older adults were underrepresented light direction the fifth attribute centred on the direction of light source discernible in the image mixed lighting was the most popular this was followed by overhead side lighting overhead lighting backlighting side lighting front lighting and underneath side lighting no images reflected a directly underneath light source by gender girls and women were slightly underrepresented in their use of mixed lighting while boys and men comprised the remaining 417 and were slightly overrepresented in their use of mixed light relative to their sample size by age teenagers were underrepresented in their use of mixed light while middleaged and older adults were overrepresented participants said overall that they only cared about light direction in their photos when it seriously interfered with intelligibility one participant said unless its the light direction really interfering with the picture i dont really care i just take it wherever and whenever i want placement context the sixth attribute concerned participants compositional approaches the most popular compositional approach was filling the frame with the subject of interest this was followed by a mixed approach and a centred approach rule of thirds framing was not widely used across the sample this type of compositional approach was only used in 57 of cases by gender girls and women were underrepresented in their use of the filling the frame approach while boys and men were overrepresented in this use by age teenagers were underrepresented in using the fill the frame approach while middleaged and older adults were overrepresented participants were asked in the followup interviews two separate questions about composition a question about how much they paid attention to whats in the background of their images and a question about their attention to photographic composition and any guiding principles that informed their compositional approach regarding awareness of the background responses ranged from none at all to considerable awareness particularly if the photos are going to be seen by others this awareness was motivated by privacy concerns voiced most frequently but not exclusively by teenage participants and concerns over elements that were perceived as distracting ugly or irrelevant overall about half of the participants said they considered the background of their images when composing a photo as with the background question some participants said they cared more about the composition when others would see the photo compared to if it was a photo just for themselves awareness of composition ranged also from none at all to a usual practice teenagers mentioned centring as a compositional approach most frequently while older adults mentioned rule of thirds framing most frequently however just slightly more than half of the sample was able to articulate a compositional approach at all the remainder of the samples members were either oblivious about composition or said they were guided by an intuitive what looks right to me approach rather than by formal principles or theory cameratosubject distance the seventh attribute used kress and van leeuwens sixpoint taxonomy of social distance and intimacy to categorise the approximate cameratosubject distance reflected in the participants smartphone photographs the most popular cameratosubject distance was the farthest away participants used this cameratosubject distance in 209 of all photographs with people following this participants made the secondmost number of photos at a head and shoulders this is followed by the photographs that show the whole figure with 193 of the sample photographs that show people from the waist up with 173 of the sample and photographs that show the whole figure with space around it with 143 of the sample participants used the most intimate social distance the most sparingly in only 8 of cases neither gender used the public distance framing more than the other by age teenagers were overrepresented in their use of the public distance framing relative to their sample share while middleaged adults were significantly underrepresented in their use of public distance framing older adults used the public framing distance in a proportionate frequency to their share of the sample one younger participant had this to say about how age seemed to impact visual intimacy and apparent frame size i feel like my friends and i get frustrated with parents when theyre zooming in a photo or they walk in really close my mom would always get one like right in my face like this is too close i dont want to see this the zoom in oh its frustrating horizontal angle the eighth attribute evaluated whether the subject of the photo was parallel or oblique to the camera participants used a slightly oblique positioning most frequently they did so in 678 of all the photos this was followed by frontal positioning in 296 of the photos and by moderate or substantial oblique positioning in 23 and 01 of the photos respectively by gender boys and men were underrepresented in their use of slight oblique positioning and girls and women were overrepresented by age teenagers were underrepresented in their use of slight oblique positioning while middleaged adults were overrepresented in their use of this positioning older adults used the slight oblique positioning in a proportion equal to their share of the sample one teenage participant noted how her age group had different preferences regarding the horizontal angle than did older adults in her parents age group she said my parents like taking faceon photos … but in our generation wed like to look like were more involved in the scene and we often have our back facing the camera vertical angle the ninth attribute evaluated whether the camera was vertically parallel to the subject or whether it looked down on or looked up at the subject the high angle was the most popular and was used with 501 of the photos in the sample this was followed by the medium angle and the low angle by gender boys and men were slightly overrepresented in their use of the high angle while girls and women were slightly underrepresented in the use of the high angle by age teenagers were underrepresented in their use of the high angle while both middleaged and older adults were overrepresented in their use relative to their share of the sample older adults said they either never thought to use different vertical camera angles or that they couldnt be bothered to do so younger adults were the only ones who mentioned using low or high angles due to their aesthetic effects when photographing people only one participant mentioned anything about the vertical camera angle and power connotations in her words i use probably medium angle more often because in my opinion its more of an accurate depiction of the person because depending whether i am high or low makes the person seem taller shorter more powerful less powerful and stuff like that so i like to use medium because its more accurate visible use of special effects the tenth attribute examined whether there was any overt use of effects or filters on the participants smartphone photos overall participants used special effects sparingly only 2 of the photos displayed obvious signs of editing and additional postprocessing by gender boys and men were underrepresented in their use of visual effects relative to their share of the sample while girls and women were overrepresented in this use by age teenagers were significantly overrepresented in their use of visual effects while both middleaged and older adults were significantly underrepresented in this use the apparent low prevalence of photo alteration or editing effects needs to be contextualised through the participants accounts of their practices first some of the younger participants said rather than edit a photo they would simply take it again when possible to achieve a better result second teenage participants said they only ever edited their photos if they were going to be posted later online this included using the spot remover tool or face smoothing effects for girls and women and cropping and filtering to improve the composition or achieve a colour consistency this was not uniformly endorsed by the teenage participants however one said i actually dont really ever use them photo alteration or editing tools i like to keep the photos looking natural it annoys me when other people alter photos because then its a bit untrue and its like theyre trying to make themselves seem better the oldest age bracket said they either got a younger relative to do any needed photo editing for them or used a computer application such as photoshop to edit their smartphone images rather than editing them directly on their phones contextualising photographic practices the studys third research question drew on the followup interviews with participants to probe at their perceptions of their smartphone photography practices it asked how do smartphone camera users explain their use of these devices to make photos the first part of this section explores the sources participants identified as having influenced their way of seeing and documenting the world through smartphone photography the second part of this section uncovers the technological affordances or constraints related to smartphone photography that participants identified teenage participants said social media were the most important influence in shaping their vision of how they see the world and document it through their smartphone cameras participants singled out instagram in particular as being particularly influential as they said they spent a lot of time on the platform and used it for inspiration and guidance on how to take photos in the words of one teenage participant i guess that social media would have also influenced that as well with the type of images that i want to take and how i hold my phone vertically and stuff like that three teenage participants also mentioned parents as being influential to how they see the world and document it with their smartphones this was particularly true for teenagers with parents who considered themselves photo hobbyists or enthusiasts outliers within the teenage category were school lessons mentioned by a single participant and visual inspiration from observing how filmmakers shoot their films the middle age bracket also said family and social media were influential to their vision the older bracket either struggled to articulate the sources that shaped their vision said it was influenced by their university studies or nominated physical media such as photography books or magazines as being influential one older participant mused that as access to media increased she observed a commensurate decrease in younger peoples sense of aesthetics in her words there seems to be a real lack of interest by younger people in say composition or the use of light or that sort of aesthetic side of getting an image when my partner and i were kids … our access to different aesthetics and images was actually very limited you had the four channels on tv you had magazines you had the occasional film you had record covers and that was it you know whereas kids these days theyre saturated with images but the aesthetic aspect doesnt seem to be that important to them regarding technological affordances of smartphone cameras and associated technologies participants noted easeofuse portability and storage capability they also noted several automated features related to cameras and camera rolls including portrait mode aigenerated collections of photos with a similar theme and oneyearago moments that participants regarded as a nice prompt to revisit that deep library of content that sits on your phone participants further noted they appreciated the ability to heart or star images and the ability in the editing interface of certain camera apps to toggle on and off edits with the tap of a finger regarding constraints of smartphone cameras and associated technologies participants perceived the cameras to be inferior in quality compared to standalone cameras they also noted the difficulty of achieving shallow depth of field photos on smartphone cameras without a portrait mode feature and perceived smartphone cameras zooms as generally inferior to those featured on standalone cameras participants also noted that using wideangle lenses would distort the scene and that the almostbottomless storage nature of smartphones presented difficulties for being able to meaningfully review and appreciate the photos in ones camera roll select participants across each of the three age groups also said they didnt use some features because they didnt know these features existed discussion and conclusion this research sought to deepen the scholarly understanding of how specific technological affordances and demographic and societal factors are affecting visual culture and therefore visual literacy in modern imagesaturated environments our results suggest that participants across the sample seemed to exhibit a reduced desire for creative control as more and more smartphone camera settings and features become automated and as a desire for efficiency overrides aesthetic sensibilities examples of this are letting the camera determine the relevant settings because they seem to work well enough and keeping the phones portrait orientation lock on as turning it off takes more time and is perceived as inconvenient we suspected that different age cohorts have different understandings of these technological affordances and different generational influences that affect their smartphone photography practices and consequently their visual literacy by including not only very young teenagers in addition to older adults in the 60s this study broadened the participant pool from the university and middleaged sample that other studies have focused on to provide a more representative understanding of everyday smartphone photography across different age groups our findings support the past work of our scholars in terms of the lower importance young people placed on selfies and the overall low level of awareness of and attention to photographic composition they demonstrated at the same time our study contributes muchneeded context about who or what young people photograph compared to older adults in revealing this wider range of photographic subjects that young people document this study underscores how the affordances of smartphone photography enable a new way of seeing and sharing that older adults who didnt grow up with this technology lack within the broad categories that previous studies of smartphone photography identified it seems based on the image analysis and contextualising interviews that both the age groups at the ends use their smartphone cameras more for affective uses to share images with close friends or family members respectively while the middle age bracket seems to use smartphone photography most for functional purposes in their daytoday lives and in the workplace in addition to paying attention to age as we have done in this study we also argue that it is critically important to study nonexpert creators as they comprise the majority of the population but are disproportionately studied in relation to affordance theory our studys participants converged with those of peters and allan in mentioning portability and easeofuse as key affordances of smartphone camera technology while our participants also noted poor zoom quality as a constraining factor of their smartphone cameras the other constraints peters allans participants mentioned were not shared by our participants this demonstrates how technological development over the past five years has rendered some of these issues obsolete while also introducing new affordances such as portrait mode aigenerated photo reels and this time last year moments and toggle onoff editing to preview the before and after version of an edited image and how these affordances affect the way that smartphone photos are made edited and viewed limitations and areas for future study one of the chief limitations of this study is the volume and richness of participant data compared to the available word count afforded by academic journals word limitations prevented us from presenting findings from the image analysis in tabular form for example and also made us select only the most representative and often mostconcise quotes over those that were outlier or rich but lengthier in practice such word count limitations discourage comparative work such as this that tries to examine different groups using multiple sources of data and in doing so limits our holistic appreciation of the phenomenon under study we are also limited as is any study involving human participants with attrition rates between different phases of the data collection this meant in some cases that some images we analysed lacked the corresponding contextualising interview data to fully complement our analysis regarding areas for future study we acknowledge that technological affordances are a dynamic and constantly evolving area so we call for continued scholarly attention to how smartphone photography practices shift alongside features enabled or constrained by technological developments we also argue that greater attention to userspecific and environmentspecific affordances is needed to holistically understand smartphone practices and outputs in the contemporary environment lastly while we appreciate the difficulties of recruiting and interviewing those at the extreme ends of the age spectrum we argue that attention to these groups is also needed to further nuance our understanding of visual language and literacy over the lifespan disclosure statement no potential conflict of interest was reported by the author note 1 it is worth noting however that not all photography happens with the default camera app and therefore appears in the users camera roll some apps such as locket allow photography with the smartphones camera but saves these images in a different place to the camera roll as such the present study doesnt necessarily account for these more supplemental photos if any that are taken on apps besides the default camera app orcid t j thomson

visual language and culture are coconstitutive and constantly evolving this transformation is more pronounced in the contemporary visual literacy landscape especially with widely used social media and more democratic technologies such as smartphone cameras which are used for myriad purposes and in diverse ways these uses and purposes vary by culture and demographics but little is understood about how smartphone cameras shape contemporary western ways of seeing visual culture and literacy specifically this study seeks to explore and identify how people living in australia use their smartphone cameras to document their everyday lives it also explores how these devices influence the participants visual languages and literacies to analyse these changes this study adopts a twomethod approach first 30 participants were recruited from three different age groups these participants donated a consistent two weeks of the images on their camera rolls for analysis these images were then subjected to an 11variable analysis second 23 participants followed through with an interview to contextualise their photographic behaviour and identify the aspects they perceive shape their ways of seeing these two methods allow an understanding of who or what is photographed as well as how and why these participants made images in certain ways

pandemic policies wrought economic instability the burden of these policies fell heavily upon disadvantaged black and latino communities where jobs permitted limited to no ability to work remotely they faced increased infectious exposure being classified disproportionately as essential workers blackowned businesses were more vulnerable often having limited reserves liquidity and credit access compared to other businesses efforts t o b lunt t he e conomic e ffect of qu arantine po licies were not distributed to the need widening the income and wealth gaps another victim of official po licy wa s ed ucational ac cess an d qu ality co mpared wi th inperson instruction virtual learning fails there was significant learning loss across the board and the achievement gap for students of color increased for example speech therapy for latino english learners rel heavily on bilingual peers for information about the social practices of language use and for translation and clarification of learning tasks clarification of learning tasks and social practices of knowledge acquisition and use applies across academic subjects for all students there was a stark contrast between the successes of whitecollar parents supervising school at home while working remotely and bluecollar parents still working at their job site with their children less closely supervised challenges among the less affluent in obtaining hardware accessing the internet and navigating the online platforms were often insurmountable creating a digital divide inefficacy of online learning was apparent in higher education online learners were more likely to withdrew from classes have lower grades and drop out completely increased disparity in the employment of adjunct vs tenured faculty emerged family medicine volume 55 issue 7 496497 health care access and quality suffered with black and latino populations disproportionately affected vaccination sites were inaccessible and both chronic and acute care were less available due to clinic closures or limited hours especially in disadvantaged neighborhoods access was further compromised by loss of insurance this increased vulnerability of populations already at greater risk for severe covid19 due to preexisting conditions school closures and the digital divide job loss health care access and disproportionate failure of blackowned business affected another sdoh namely neighborhood and the built environment closure of other neighborhood businesses further rendered services and infrastructure inadequate pandemic policies altered social and community context perhaps one of the more significant social injuries to black communities was pandemic policies on religious practice religion has mitigated the full impact of certain negative outcomes for blacks in the past but with enforced closure of houses of worship there was a loss of this significant source of social support disasters follow a cycle of preparation response recovery and mitigation covid19 and the response to it was a disaster the authors propose highreturn interventions to aid in the recovery mitigate the damage to black and latino populations and better prepare for the next event these focus on child education and health adult job training criminal justice housing wealth building and intergenerational interventions this is the right thing to do our vulnerable populations whether by error or design present an early warning sign policies and practices that hurt them ultimately harm even those who have advantage in the sdoh if pure compassion and justice doesnt move society to avoid bad policies selfish pragmatism must

for years family physicians have advocated a biopsychosocial model of medicine slowly health systems payers and government policy makers awakened and began to consider the social determinants of health sdoh then came covid19 immediately everything narrowed in focus to merely the biological stop the virus as society shut down there was no consideration of economic stability education health care access and quality neighborhood environments or social context 1 it may be years before we know whether this response to the pandemic had a net positive neutral or negative effect o n overall morbidity and mortality the pandemic divide suggests that the result was largely negative for at least some segments of society this collection of essays with the primary intent of illustrating … the broad reach of structural racism p xii explores how covid19 and the resulting policies disproportionately worsened health the authors point out that while most studies of the pandemics effects o n b lack a nd l atino c ommunities f ocus o n preexisting health disparities effects on other aspects of their lives read sdoh are neglected p 69 a major contribution of this book is its examination of these other aspects citing the limited data that exist the authors incorporate personal stories that illustrate the devastating impacts

introduction in contrast to other countries the australian population has access to a firstclass universal healthcare system and is relatively healthy 1 aboriginal and torres strait islander peoples are an exception to this rule the gap in health outcomes and life expectancy between aboriginal and torres strait islander peoples and other australians has been widely reported 1 2 3 the rate of death for aboriginal and torres strait islander children is more than twice that for other children 2 this disparity in health outcomes extends to disability 4 increasingly there is recognition of the importance of the social determinants of health and of health as a human right social determinants of health and human rights although there are social gradients in the incidence of disability it is reported that little attention has been paid to research on the social determinants of health in disability policy 5 policy has the potential to act as a structural determinant of health 6 the australian human rights commission has drawn attention to a number of human rights violations faced by aboriginal and torres strait islander persons with a disability these include individual rights to health and education that are impacted by the high levels of socioeconomic disadvantage 7 the link between disability and poverty is bidirectional 8 in the united states and canada indigenous populations also experience the negative impact of socioeconomic disadvantage on service access 9 10 11 racism is another key social determinant of health that negatively impacts service access 12 experiences of direct and indirect racism have been linked to distrust of mainstream organizations and providers 213 health disparities in childhood disability aboriginal and torres strait islander children experience a higher prevalence of disability than other children 4 they encounter higher rates of hearing loss 1415 which has been linked to the high prevalence of middle ear diseases such as otitis media rates of om experienced by aboriginal and torres strait islander children are among the highest in the world similar to those in low income countries and at a level classified by the world health organization as a massive public health problem 21617 om is also experienced for longer and more persistent periods by aboriginal and torres strait islander children 1819 aboriginal and torres strait islander children have also been found to have a significantly higher prevalence of communication disorders 20 and are 13 times as likely to require assistance with selfcare mobility or communication than other children 21 such disparity is also evident in developmental delay 2223 early intervention is vital as high rates of disability can negatively impact education speech language and social development and employment outcomes 13141719 24 25 26 it is also acknowledged that intervening at the early stages of childhood development is more costeffective than intervening later in life 27 social determinants of health and aboriginal and torres strait islander childhood disability aboriginal and torres strait islander children not only experience a higher prevalence of disability but are also disproportionately affected by socioeconomic disadvantage 2 almost half of aboriginal and torres strait islander households are in the lowest income group and are 4 times less likely to be in the highest group than other australians 2 socioeconomic disadvantage directly impacts disability for aboriginal and torres strait islander children 25 who are more likely to experience negative developmental outcomes from disabilities like omrelated hearing loss due to social determinants of health 18 addressing the influence of social determinants of health on aboriginal and torres strait islander childhood disability requires a shift in thinking as they are often considered indirect to the traditional responsibilities of health education and social service sectors 252829 barriers to service access aboriginal and torres strait islander children with a disability and their families face many barriers to service access 25 a key barrier is the confusion caused by complex and fragmented service provision across government departments and agencies working in professional silos 3031 this lack of integration is often described by a silo approach a silo refers to systems and processes that operate in isolation from each other policy response to improve service access the need for holistic and collaborative responses to disability is recognized internationally 8 the world report on disability identifies that policies within health education and social service sectors all impact on disability outcomes 8 nationally the australian governments close the gap campaign to reduce aboriginal and torres strait islander disadvantage advocates the need for collaboration across all sectors and levels of government for effective service coordination 32 the national policy direction towards collaboration and wholeofgovernment approaches is reflected in a number of disabilityspecific policies and strategic frameworks 3 33 34 35 36 little is known about aboriginal and torres strait islander children with a disability 4 despite the policy push towards collaboration there has been no systematic attempt to elucidate how collaboration works in practice across and within sectors involved in service provision therefore the current authors set out to answer the question what are the important components involved in interand intrasector collaboration in aboriginal and torres strait islander childhood disability understanding these components will be essential in improving service provision and access for aboriginal and torres strait islander children with a disability and their families methods we conducted an integrative literature review using a systematic approach to identify components of collaboration guided by an investigatordeveloped protocol eligibility criteria disability is a complex concept with no universally agreed definition 8 for the purposes of this review disability refers to longterm physical mental intellectual or sensory impairments that interacting with environmental and attitudinal barriers hinder full and effective participation in society on an equal basis with others 37 included articles focused on aboriginal and torres strait islander children with a disability andor their families carers or providers of services to this population and include reference to collaboration or interaction within or across two or more providerssectors we included articles in the english language specifically addressing australian issues no publication date limits were imposed and all study designs were included be they quantitative qualitative or mixed methods commentaries were also included articles were included regardless of whether they were published in peerreviewed journals or grey literature articles were excluded if their sole focus was on adolescent or adult disability or a population other than aboriginal and torres strait islander peoples search strategy a systematic electronic database search strategy using boolean terms was developed in collaboration with a health librarian search terms were medical subject headings terms and keywords including derivatives of the key terms collaboration child disability and indigenous the grey literature was searched using variations of the key search terms from each of these groupings information sources a systematic search of health education social science multidisciplinary and indigenous electronic databases was conducted to identify articles published in peerreviewed journals grey literature was identified through a search of websites of aboriginal and torres strait islander and disability representative organizations the national disability organisations clearinghouse trove theses database and mednar from 23rd may 4th june 2014 grey literature identified during the search for articles published in peerreviewed journals was also reviewed study selection returned articles published in peerreviewed journals were imported into endnote software one hundred articles were assessed against eligibility criteria independently by two researchers any inconsistencies were discussed until consensus was reached one researcher assessed the remaining articles data collection data were extracted from the original text of included articles by ag into an a priori designed electronic spreadsheet data items included the setting design disability impairment population aims and methods data items specific to collaboration were extracted and grouped according to the discipline of providers involved in collaboration collaborative models components of collaboration and key conclusions or recommendations evaluation and analysis quality appraisal of the articles published in a peerreviewed journal was conducted as part of a systematic approach to provide an overview of quality but was not given weighting in the analysis and synthesis of data due to the lack of formal methods for this in integrative reviews quality appraisal of all included articles published in a peerreviewed journal was conducted independently by two researchers who met to establish agreement on the final rating any disagreements were resolved through discussion the following critical appraisal tools were used criteria for assessing qualitative literature 38 the strengthening the reporting of observational studies in epidemiology checklist 39 the transparent reporting of evaluations with nonrandomized designs checklist 40 the mixed methods appraisal tool 41 and the measurement tool to assess systematic reviews checklist 42 to assess qualitative observational intervention mixed methods and review studies respectively all included articles were evaluated using the level of evidence ranking system by meinyk and fineoutoverholt 43 data analysis was guided by the narrative synthesis approach by popay et al 44 after developing the preliminary synthesis of findings we searched for a conceptual model the model needed to provide a holistic framework centered on the child and their family that encompassed the different system levels of collaboration and how they interact with one another an adaptation 45 of bronfenbrenners ecological model for child development 46 represented a conceptual model in which the relationships in the data could be explored at the macro exo and meso system levels the ecological model has previously been referenced in the context of addressing factors influencing equitable service access for underserved populations with a communication disability 47 to our knowledge it hasnt before been applied specifically to service access issues in aboriginal and torres strait islander childhood disability this organizing framework reflects factors that interact to achieve a desired outcome and also the impact of social interaction addressing each element discretely without considering the interdependency of elements is unlikely to achieve desirable outcomes results the database search and peerreviewed article selection is depicted in figure 3 thirteen peerreviewed articles met inclusion criteria the majority of studies were qualitative followed by discussion papers observational intervention mixed methods and literature review the grey literature search retrieved 18 articles that met the inclusion criteria in total 31 articles were included in the review the literature predominantly reported on hearing impairment and related disability such as learning impairments of the included articles 14 provided details on 12 different models involving interand intrasector author observations and reflections no collaboration the majority of these models centered on collaboration within different areas of the health sector and between the health and education sectors half of the models were set in schools or early childhood centers and the most common model component was a form of capacity building overall the qualitative studies were generally wellreported according to kitto et als criteria for assessing qualitative literature 38 that evaluated clarification of research data collection techniques justification of qualitative approach and interpretation none of the studies reported on whether the sampling techniques supported generalizability and seldom demonstrated transparency of data analysis or researcher reflexivity the mean strobe score for the observational studies was 16 out of 22 both studies reported well on rationale study design setting variables data sources outcome data and generalizability neither study reported on the eligibilityselection of participants study size or study limitations the trend score was 15 out of 22 for the intervention study which reported well on background methods and results but not generalizability the mixed method study received a mmat score of 50 for the qualitative component reporting well on data sources and relationship between findings and context but not on analysis or researcher influence 75 for the quantitative component reporting well on sampling strategy measurements and response rates and 50 for the mixed method component reporting well on research design but not limitations the literature review received an amstar score of 78 for the 9 applicable items and reported well on study selection data extraction search strategy study characteristics and quality assessment of studies the literature review did not provide a list of excluded studies and there was no assessment of publication bias the following section provides a narrative synthesis of the findings using the macro exo and meso system levels of the ecological model to demonstrate the components of interand intrasector collaboration in aboriginal and torres strait islander childhood disability macro system factors factor structure of government departments and agencies the siloed structure of health education and social service departments and agencies was found to impede service integration and the ability of providers to work collaboratively 48 siloes of service provision across government departments and agencies and between levels of government 49 negatively impacts service access for families when they have to navigate different waiting lists and assessment processes and receive disparate pieces of information from professionals working in isolation 485051 the fragmentation and complexity of government services 52 impede opportunities for collaboration with some providers reporting difficulties in locating and communicating with relevant services 5253 the adoption of a consultative approach across health education and social service departments has been recommended as a solution for reducing service duplication and fragmentation and is more aligned with the needs of the childwhich are beyond the biomedical and include social cultural economic and psychological issues 50 factor policies collaboration at the level of policy making can address the barriers generated by existing structures of government departments and agencies formalized agreements like memoranda of understanding and collaborative frameworks between government sectors can facilitate collaboration at the level of service provision 54 mous between the health and education sectors have promoted collaboration between health professionals and school staff in screening and treatment of middle ear disease to prevent hearing loss 5455 frameworks for wholeofgovernment approaches have been recognized as important in providing coordinated interagency responses 56 57 58 formalized agreements should focus on detailing a set of long mediumand shortterm strategies as it provides clarity around collaborative programs for local providers 5559 exo system factors factor communication awareness although multiple agencies and services may be involved with the care of a child with a disability this does not mean that they are all aware of each others existence which can lead to duplication of resources 60 both families and providers have identified the lack of communication between and knowledge of the different agencies and services as a barrier to accessing available support 53 raising awareness of collaborative partnerships through the distribution of educational resources across agencies and services facilitates collaboration and the professional development of providers with little knowledge of disability 525556 distribution of these resources helps providers in remote areas of australia who have reported feeling like they work in isolation 61 advertising collaborative projects and the participating personnel also aids collaboration by reducing the risk associated with providers working outside their professional boundaries 50 good community awareness of the organization that is providing a program has also been reported to facilitate the establishment of collaborative organizational partnerships with local services 62 factor communication lack of role clarity and responsibility ambiguity and lack of role clarity and responsibilities of different providers agencies and organizations is a key barrier to collaboration at the exo system level 57 the role of aboriginal health workers is unclear to some mainstream providers leading to their underutilisation despite the important role they play 20 formally communicating the role and responsibility of each team member is reported as an essential step when putting into practice an interagency or multidisciplinary model 50 factor financial and human resources barriers to the uptake and sustainability of collaborative models include difficulty providing them in sectors that are already facing service provision within a tightening financial environment 48 and a lack of the levels of funding required for providing holistic care approaches 6364 where organizations continue to provide collaborative models of service provision despite lack of appropriate funding they report that this is done so on sheer good will 63 with staff often working beyond their normal hours 64 building effective and trusting collaborative relationships across different organizations agencies and services takes time 576265 collaboration can be impeded when providers lack the time to develop the skills and build the networks required 53 factor service delivery setting the effectiveness of a collaborative program is influenced by the setting in which it is delivered collaboration is facilitated by the delivery of mainstream programs in culturally safe environments for aboriginal and torres strait islander providers communities and families 515366 delivering collaborative health services within schools has been reported to reduce the stigma and the socioeconomic impact of having to attend services in mainstream settings for aboriginal and torres strait islander families while increasing program participation 6667 basing health services within schools also allows the services to be responsive to local needs and promotes increased awareness of disability and relevant services among education providers 5567 collaboration between health and education services based in a single setting provides a onestopshop which facilitates the sharing of information between different services and organizations 52 meso system factors a number of key factors of collaboration are found at the front line of collaborative service provision within the meso system where the interactions occur between providers communities and aboriginal and torres strait islander families and their children factor relationships a key facilitator to collaboration at this level is the coordinator or linking role the appointment of a person external to the services or agencies involved whose role is to link the different players and act as a trainer motivator and sustainer can be important to a collaborative interdisciplinary approach 506869 in the context of aboriginal and torres strait islander childhood disability this person is usually local to the community and is a conduit between providers communities and families also promoting the cultural competence of services 52606466677071 the effectiveness of the coordinator or linking role in facilitating collaboration is influenced by the individuals characteristics being open and inclusive and having personal contacts among decision makers in the organizations agencies and services involved promotes collaboration 50 the effect of individual characteristics on collaborative relationships extends to providers collaboration can be impeded by specialist providers choosing to only draw knowledge and skills from their traditional disciplines 48 aboriginal and torres strait islander provider experiences of racism and historical trauma can obstruct engagement with mainstream services 53 awareness of cultural difference and individual attitudes 72 and getting along well with people 66 are individual provider characteristics that can facilitate collaborative relationships transience and turnover of key staff can disrupt collaborative efforts 505668 building relationships integral to collaboration at the local level is facilitated by facetoface provider engagement and linking with communities 485873 providertoprovider engagement is facilitated by demonstrating mutual respect and understanding 5072 having access to direct links for communication and using open and respectful communication strategies 5051 the importance of engagement is reflected in the collaborative specialist integrated community engagement model that is based around the concept of linking different sectors and the community through engagement to build social capital and a community of learners to sustain the collaborative process 48 engaging the community can be important to the success of collaborative programs 74 and tapping into existing collaborative relationships in the community can facilitate the engagement process 67 where a mainstream organization is unknown to a community attending interagency meetings in the local area by their providers can facilitate engagement with aboriginal and torres strait islander organizations 62 factor interand intraprofessional learning the modeling of interand intraprofessional collaboration by clinical educators from different disciplines for university students on placement has been reported to facilitate a wellcoordinated and holistic approach to learning 72 the sustainability of collaborative practices is increased by empowering students to incorporate the lessons learned into their future practice 72 interand intraprofessional learning also facilitates collaboration by creating supportive relationships between providers from different disciplines 66 discussion the findings of this review depict a national snapshot of collaboration addressing the limited understanding of how collaboration works in practice in the field of aboriginal and torres strait islander childhood disability the complex nature of childhood development particularly for aboriginal and torres strait islander children has seen recognition of the need for a shift from a purely medical view of disability to collaborative approaches that also take into account social and environmental factors 474853 divisions between mainstream specialist and nonmainstream services can result from topdown approaches that do not work for addressing complex problems which require buyin to collaborative approaches at all levels 3075 in the move towards collaboration however it is important to recognize that collaboration is in itself a complex concept which has the potential to inspire innovative solutions or create frustration 76 further research is required into collaborations in aboriginal and torres strait islander childhood disability to maximize the potential and minimize any negative impacts of collaborative approaches the paucity of research on aboriginal and torres strait islander children with a disability 4 also means exploring the experiences of children and their families in accessing services is important to completing a holistic picture in order to improve service access the importance of respectful communication and culturally appropriate program delivery as found in this review demonstrates the need for cultural competence as a central pillar of collaboration in aboriginal and torres strait islander childhood disability cultural competence requires promotion of attitudes knowledge and behavior at individual institutional and systemic levels in order to deliver effective care for aboriginal and torres strait islander peoples 77 culturally competent organizations and systems need to be reflective of the diverse populations they serve including at leadership and management levels and through policies which facilitate crosscultural communication and access 78 an increased focus on cultural competence may help to address the negative impact of racism on service access and provision although the review focused on aboriginal and torres strait islander children and is not necessarily generalizable to other indigenous populations similar health disparities are experienced by indigenous populations worldwide 9104779 investment of time as a facilitator to building sustainable collaborations in the face of government policy and funding cycles is reflected in canadas collaborative aboriginal head start program to improve indigenous child development outcomes a key element to the positive impact of the communitybased program is the time it took to establish credibility within communities and build a trained and experienced workforce to work collaboratively 9 longterm commitment to sustainable and collaborative relationships with indigenous organizations and communities is also a strategy identified by aboriginal and torres strait islander organizations to achieve genuine partnerships 80 building workforce capacity has been recommended as a key element in improving service access for people with a disability and addressing the social determinants of health 847 health providers in particular have been identified as key players through advocacy working in partnerships and working with communities 81 collaboration is more likely to be achieved through personal relationships than imposed structures 82 further emphasizing the important role of health education and social service providers in improving service access for aboriginal and torres strait islander childhood disability through collaboration limitations the conclusions of systematic reviews are inevitably limited by the breadth and quality of the research available for inclusion literature relevant to the topic of interest has been mostly discursive with only eight empirical studies published in a peerreview journal only one of which has tested an intervention the focus of the review on aboriginal and torres strait islander children with a disability across australia may mean that it is not generalizable to indigenous populations in other countries or to specific aboriginal and torres strait islander populations within australia this review provides a broad national snapshot of collaboration but further research within specific local contexts is required to explore ways collaboration can improve access and be responsive to local needs 880 due to the focus of the review on interand intrasector collaboration no data for the microsystem of the family and the individual child were collected the intraand interpersonal factors and interactions at this level however both influence and are influenced by the factors of collaboration at the meso exo and macro system levels conclusions the policy shift towards intersector collaborative approaches represents a strong opportunity for the health education and social service sectors and their providers to work collaboratively with each other in innovative ways as this review has shown however collaboration is not a simple concept many barriers and facilitators exist at the macro exo and meso system levels that influence the effectiveness of collaborative efforts by identifying the components of interand intrasector collaborations this review provides information to guide future efforts at developing collaborative solutions to improve service access for aboriginal and torres strait islander children with a disability and their families competing interests md pd pa and jd authored two of the articles included in the current review quality appraisal of these articles was conducted by ag and tl to reduce bias and quality appraisal did not influence the findings of the review the author declare that they have no other competing interests authors contributions ag contributed to study conceptualization and design data acquisition and analysis and drafted the manuscript md contributed to study conceptualization and design interrater checks of data acquisition and appraisal and manuscript revision tl contributed to study design interrater checks of data acquisition and appraisal and manuscript revision pa pmd and jd contributed to study conceptualization and manuscript revision pd contributed to study conceptualization manuscript revision and cultural mentorship all authors read and approved the final manuscipt author details 1 center for cardiovascular and chronic care faculty of health university of technology sydney po box 123 broadway nsw 2007 australia 2 university of western sydney locked bag 1797 penrith nsw 1797 australia 3 school of nursing johns hopkins university 525 n wolfe street baltimore md 21205 usa 4 aboriginal medical service western sydney po box 3160 mt druitt nsw 2770 australia

introduction aboriginal and torres strait islander children in australia experience a higher prevalence of disability and socioeconomic disadvantage than other australian children early intervention is vital for improved health outcomes but complex and fragmented service provision impedes access there have been international and national policy shifts towards intersector collaborative responses to disability but more needs to be known about how collaboration works in practice methods a systematic integrative literature review using a narrative synthesis of peerreviewed and grey literature was undertaken to describe components of interand intrasector collaborations among services to aboriginal and torres strait islander children with a disability and their families the findings were synthesized using the conceptual model of the ecological framework results thirteen articles published in a peerreviewed journal and 18 articles from the grey literature met inclusion criteria important factors in interand intrasector collaborations identified included structure of government departments and agencies and policies at the macro government system level communication financial and human resources and service delivery setting at the exo organizational system level and relationships and interand intraprofessional learning at the meso provider system levelthe policy shift towards intersector collaborative approaches represents an opportunity for the health education and social service sectors and their providers to work collaboratively in innovative ways to improve service access for aboriginal and torres strait islander children with a disability and their families the findings of this review depict a national snapshot of collaboration but as each community is unique further research into collaboration within local contexts is required to ensure collaborative solutions to improve service access are responsive to local needs and sustainable

introduction through an effective social media campaign the islamic state of iraq and ashsham has issued a powerful global call to arms on youtube twitter and a host of other social media platforms an ethnically diverse set of jihadists issue a similar calls to would be fighters living in the west their message promises heaven to those who answer their call to arms this strategy initially was used to motivate foreign fighters to join isis campaigns in syria and northern iraq 1 but online radicalization appears to be a critical component of the groups shift toward decentralized attacks in the west 2 online extremism can be defined as advocating support of groups or causes that in any distribution of opinion would lie on one of the tails 3 although the methods and ends espoused by isis online marketing campaign clearly meet the definition of extremism the campaigns global reach has generated an operationally significant amount of online and offline support as of january 2015 united states intelligence sources estimate isis had between 9000 and 18000 fighters in iraq and syria 4 although the majority of isis fighters are from the middle east and north africa a surprising number of fighters have arrived from the western world isis message has global reach and has even motivated lone wolf attacks in canada 5 france 6 the united states 7 and the united kingdom 8 not all members of isis online community display the same levels of online extremism some claim unaffiliated sympathizers who simply retweet or repost propaganda represent a paradigmatic shift explaining isis unprecedented online success 9 10 11 12 in many cases these unaffiliated users activity although offensive to many is not in clear violation of law or the twitter rules 13 however this large body of passive supporters contribute to the volume of isis related content proliferated on twitter and appears to be a vital component of isis social media campaign these individuals are therefore of interest to any effort to counter online extremism some of these passive sympathizers become recruiting targets isis uses small teams of social media users to lavish attention on the potential recruits and move the conversation to more secure online platforms 12 thus while twitter may not be the place where recruitment ends growing evidence suggests that identifiable patterns of recruitment begin on twitter the primary goal of this work is to provide methods allowing researchers to gain insight into this online social network of unaffiliated sympathizers propagandists fighters and recruiters and how these users interact to create a thriving online extremist community we argue that such understanding is needed to create counternarratives tailored to the online populations most vulnerable to this type of online extremism to do so we must first solve another problemidentifying an oec on twitter this task is difficult for three reasons first the size of oecs varies and is often unknown with respect to isis it has been estimated that the oec is between 46000 and 70000 strong 11 however the relatively small intersection between existing datasets maintained by activists and researchers indicates the group could in fact be much larger second current social media community detection methods require a great deal of manual intervention or provide unacceptable precision via automated methodsthere is thus an existing tradeoff between manual coding of the data and highly inaccurate classification tools in the existing literature as isis popularity has grown so too has its opposition thus the isis oec and extremist groups in general tend to be covert in that they actively attempt to avoid some form of detection twitter now systematically identifies and suspends user accounts associated with the group 14 in fact twitter has initiated a systematic campaign to neutralize isis use of the site and announced in march of 2016 the suspension of over 125000 isis supporting accounts in a six month period 15 furthermore activist groups like anonymous and lucky troll club have used crowd sourcing to identify and expose isis oec members on twitter 16 17 18 these attempts to limit isis use of social media platforms has resulted in a predatorpreylike system where the isis oec on twitter has begun show systematic attempts to make the network anonymous and resilient our work makes three major contributions to the literature first we present iterative vertex clustering and classification a novel approach to detect and extract knowledge from oecs our approach utilizes community optimization methods in conjunction with multiplex vertex classification a classification method used on heterogeneous graphs that leverages the rich data structures common to many osns like user metadata mentioning following and hash tag use capitalizing on this rich structure enables us to outperform existing methods with respect to recall and precision which will be shown in section 4 after considering the merits of our approach we then turn to the second major contribution of this work an illustrative case study of the isis oec on twitter by searching known members following ties and partitioning the resultant network we identify a community of over 22000 twitter users whose online behavior contributes to the online proliferation of isis propaganda we leverage clustering and twitter suspensions to infer positive case instances with our classifier which is able to partition our training set with 96 accuracy this offers significant improvement over existing methods and we claim this makes our output uniquely valid for the study of online radicalization finally we discuss an ethical framework for the implementation of methods similar to ivcc we highlight the framework presented in 19 of methods context and target and we draw distinctions in context between diplomatic and intelligence applications of social media mining we structure this article as follows in section 1 we discuss related work and highlight the limitations of common community detection methodologies with respect to oec detection section 2 provides a detailed overview of our proposed community detection methodology followed by an illustrative case study of the isis oec on twitter in section 3 section 4 provides a detailed discussion of the relative performance of ivcc and section 5 provides a case study of the isis supporting oec on twitter and illustrative knowledge extractions useful for countermessaging or intelligence purposes we then discuss the societal implications and limitations associated with the potential uses of our methods in section 6 and propose future research in section 7 background krebs 2021 was the first to cast largescale attention on network sciencebased counterterrorism analysis with his application of network science techniques to gain insight into the september 11 2001 world trade center bombings although similar methods were presented years earlier 22 the timeliness of krebs work caught the attention of the western world and motivated a great deal of further research 23 24 25 26 27 28 29 much of this work focused on constructing networks based on intelligence and using the networks topology to identify key individuals and evaluate intervention strategies the rise of social media has introduced new opportunities for network sciencebased counterterrorism and some foresee social media intelligence as being a major intelligence source in the future 30 this presents a fundamentally different counterterrorism network science problem roughly as opposed to using information about individuals to build networks we now use networks to gain insight into individuals typically we are also trying to identify a relatively small and possibly covert community within a much larger network such a change requires methodologies optimized to detect covert networks embedded in social media the problem of community detection has been widely studied within the context of largescale social networks 31 community detection algorithms attempt to identify groups of vertices more densely connected to one another than to the rest of the network social networks extracted from social media however present unique challenges due to their size and high clustering coefficients 32 furthermore ties in online social networks like twitter are widely recognized to represent different types of relationships 33 34 35 36 the algorithms of newman 37 and blondel 38 are recognized as a standard for comparison for community detection within network science within the broad landscape of all community detection algorithms the work of both newman and blondel fall under the umbrella of what is more accurately referred to as community optimization algorithms in community optimization algorithms the graph is partitioned into k communities based on an optimization problem that centers around minimizing intercommunity connections are minimized and k is unspecified surprisingly both newman and blondel operationalize this minimization problem as a maximization one where they maximize modularity the modularity of a graph is defined in eq 1 in eq 1 the variable a ij represents the weight of the edge between nodes i and j k i ∑ j a ij is the sum of the weights of the edges attached to vertex i c i is the community to which vertex i is assigned δ is the inverse identity function and m ¼ 1 2 p ij a ij q ¼ 1 2m x ij ¼ a ij à k i k j 2m dðc i c j þð1þ eaton and mansbach 39 have introduced methods from constrained clustering literature to enable semisupervised community optimization where a subset of vertices have known memberships as well while such algorithms work well for certain classes of problems community optimization algorithms have shown limited ability to detect threat networks embedded in social media when the group maintains connections with nongroup members 35 community optimization is also unable to effectively account for multiplex graphs or graphs with multiple connection types like community optimization graph partitioning finds partitions by minimizing intragroup connections however the number of groups k is fixed 31 covert network detection is then best described as a special case of graph partitioning where the partition is binary 40 smith et al 40 effectively use this viewpoint to model spatiotemporal threat propagation using bayesian inference however their method does not extent to multiplex or multimode graphs when applied to social media to do so other methods must be used in recent years another subclass of community detection methods has emerged community detection in annotated networks this body of work attempts to effectively incorporate node level attributes into clustering algorithms to account for noisiness of social networks embedded in social media vertex clustering originates from traditional data clustering methods and embeds graph vertices in a vector space where pairwise euclidian distances can be calculated 31 in such approaches a variety of eigenspace graph representations are used with conventional data clustering and classification techniques such as kmeans or hierarchical agglomerative clustering and support vector machines these methods offer the practitioner great flexibility with respect to the types of information used as features vertex clustering and classification methods have been shown to perform well with social media because of their ability to account for a great variety of vertex features like user account attributes while still capitalizing on the information embedded in the graph they also perform well at scale 3441 34 introduces a vertex clustering framework sociodim which detects communities embedded in social media by performing vertex clustering where network features are represented spectrally and paired with user account features very similar methods are also presented in 42 41 then applies sociodim to classification which is analogous to a binary partition of the graph these methods show clear promise with respect to covert network detection in social media as illustrated by 35 eigenspace methods have been shown to adequately model multiplex representations of various types of social ties in social media 43 and early studies of simulated networks indicate they would perform well on threat detection in social media 35 we hypothesize that eigenspace representations of multiplex social networks embedded in social media when paired with user account features and node level features will provide a more powerful means to detect extremist communities embedded in social media our work utilizes community optimization across multiple graphs in an annotated heterogeneous network to facilitate vertex classification and detect a targeted covert community in sum we have found that each of the methods listed above offer useful information for classification but a combination of these techniques must be used to effectively detect covert networks embedded in social media methods iterative vertex clustering and classification the goal of finding an oec within a larger dataset can be formalized as attempting to find a relatively small subgraph within a large annotated heterogeneous network g the full network g is a directed weighted graph with vertex sets v 1 v n each vertex set contains vertices v n1 v nj with one or more edge types e 1 e 2 e m we define a subset of targeted vertices a t v t and denote its complement as ãt our goal is to accurately classify each vertex in v t as members of either a t or ãt for example in our case study we define a t as our set of isis oec members and ãt as the union of both nonmembers and official accounts which will be defined below in practice we will often have partial knowledge of the group and its members and need to leverage as much information as possible to identify vertices in a t our methodology leverages a priori knowledge to search for and detect a covert subgraph in social media by iteratively utilizing community optimization and vertex classification our approach is thus conducted in two phases in phase i community optimization algorithms and a priori knowledge are used to gain insight into the larger social network and facilitate supervised machine learning in phase ii phase ii partitions vertices retaining only those in a t thus finding the targeted covert community a diagram of the process can be seen in fig 1 phase i vertex clustering and community optimization although community optimization and vertex clustering methods will often fail to accurately partition our networks into a t and ãt 35 we can often look for community structure within the network to gain insight into the set of vertices in a t for example if a subset of vertices from a t is known community optimization can identify clusters containing a large proportion of those known vertices belonging to a t community optimization can also identify groups of vertices that are clearly members of ãt the insights gained from community optimization help provide necessary context with respect to algorithm selection and case labels for vertex classification in phase ii of our methodology phase ii multiplex vertex classification like 41 we classify v t1 v tj using a set of features extracted from the users social media profiles and spectral representations of the multiplex ties between v t we denote these spectral representations as u v t ×vtei where i 1 m to develop spectral representations of our heterogeneous network we symmetrize the graphs w g v n ×vnem for 8e m these symmetric graphs also leverage the strength of reciprocal ties which have been shown to better indicate connection in social networks embedded in social media 44 45 46 in our case study we refer to the symmetrized network of following ties as f rec and the symmetrized network of mention ties as m rec we then extract the eigenvectors of the graph laplacian associated with the smallest two eigenvalues as highlighted in 47 and we concatenate these matrices as presented in 43 this enables us to effectively capture the distinct ties represented in many types of social media as well as node level metrics of each graph and user account features users can often use topical markers like hash tags in twitter and these can be used to cluster users with similar topical interests this results in bipartite graphs g v t ×vnem where users and topical markers represent differing node sets however we with to use these links to find similarities with respect to topical interests among users to do so we implement bispectral clustering as introduced by 48 as a document clustering method in our case instead of coclustering documents based on word frequency we cocluster users based on hashtag frequency within their tweets to do so we develop w v t ×vn where w ij 2 w v t ×vn represents the number of time vertex v nj appears in the twitter stream of v ti to cocluster v t1 vtn we follow the biparitioning algorithm provided in 48 which results in eigenvector features similar to those we defined in the previous paragraph the combination of user account attributes node level metrics from the larger network g and spectral features explained above provide a rich feature space paired with a reasonably sized set of labeled vertices we can detect an extremist community embedded in social media with supervised classification if labeling vertices is impractical and node attributes appear informative vertex clustering methods can be used as in 34 although we implement two different binary classifiers in section 3 specific algorithms selected for either phase of this methodology are the decision of the researcher the end result of ivcc an accurate extraction of vertices a t facilitates a social network analysis of the oec of interest case study the isis oec on twitter to illustrate the utility of our methodology we offer a case study of the isis oec on twitter this case study aims to validate our proposed methodology present its limitations in terms of ethical use and provide illustrative examples of intelligence that can be mined from oecs although the results of our case study provide strong results in terms of accuracy and we have provided both traditional and sampling based methods for performance evaluation we stress that we see these methods primarily as a means to understand the interests and behaviors of this oec as with any classification technique false identification of isis oec members must be considered by the practitioner and using ivcc to support any type of intervention should be used within the context of multiple sources of intelligence we discuss intended use and the societal implications of similar methodologies in detail in section 4 isis data in this section we describe both our collection methods and dataset but before doing so we would like to clearly state that we have complied with all of twitters terms of service and privacy policies 49 we also make no attempts to bind online and offline identity and have deidentified all users in the data shared in within this manuscript as a result no ethics or irb approval was obtained or required to develop our dataset we instantiate our sampling strategy with five known influential isis propagandists highlighted in 50 in november 2014 we conducted a two step snowball sample 51 of these users following ties using the twitter rest api snowball sampling is a nonrandom sampling technique where a set of individuals is chosen as seed agents the k most frequent accounts followed by each seed agent are taken as members of the sample this technique can be iterated in steps as we have done in our search although this technique is not random and prone to bias it is often used when trying to sample hidden populations 11 step one of our search collected user account data for our 5 seed agents 1345 unique following ties step 2 resulted in account information for all users followed by the 1345 accounts captured in step 1 our search resulted in 119156 user account profiles and roughly 862 million tweets this network is multimodal meaning that it has two types of vertices and multiplex because it has multiple edge types we represent this set of networks as a heterogeneous social network with annotated nodes 52 g with two node classes users and hashtags and four types of links following relationships mention relationships and userhashtag links summary statistics of each network are provided in table 1 the snowball method of sampling presents unique and important challenges within social media users social ties often represent their membership in many communities simultaneously 53 at each step of our sample this results in a large number of accounts that have little or no affiliation with isis the core problem of the present work is to identify the set of users within the 119156 accounts collected that support isis in varying degrees in order to do so we required a rigid definition of what it means to support isis we define the following three user types of interest • isis oec member similar to 11 we code users who unambiguously support isis as oec members for example if the user positively affirmed isis leadership or ideology glorified its fighters as martyrs affirmed isis call to jihad as a duty for all muslims or used proisis images in their profile we coded them as oec members furthermore in light of the growing emphasis placed on passive observers 9 we infer retweets as endorsement therefore a members support is relative and in many cases not in violation of local law or twitters terms of use however including this broad continuum of support facilitates the study of populations that could be more susceptible to radicalization • nonmember a user whose tweets were either clearly against isis or showed no jihadist content • official account we label vertices as official accounts if they meet any of the following criteria the users account identifies itself as a news correspondent for a validated news source the account is attributed to a politician government or medium sized company or larger or following 11 if the account has more than 50000 followers this third categorization was deemed necessary as in the process of our case study we identified dense following and mention ties between isis oec members and news media politicians celebrities and other official accounts such accounts are interesting in that there higher follower counts and mention rates tend to make them appear highly central even though they do not exhibit any isis supporting behaviors official accounts must be identified and removed for accurate classification of isissupporting thus illustrating the utility of an iterative methodology ivcc implementation by sampling user accounts from g it is clear that the preponderance of accounts collected have no visible affiliation with isis but we like 11 expect an isis supporting community to be captured by our sampling strategy however community optimization results of the mention m and following f networks highlight an interesting phenomenon we used the louvain grouping method presented in blondel et al 38 to cluster m and f in each case we found that our 5 seed agents were assigned to one of two clusters for example clusters 4 and 6 of the mention network contained all 5 of our seed agents during the time period between our data collection and analysis november of 2014 to march of 2015 twitter has initiated an aggressive campaign to suspend isis supporting users 54 and we found the clusters containing our seed agents to have excessively high suspension rates for example clusters 4 and 6 of the m network had suspension rates of 41 and 21 respectively as shown in fig 2 no other cluster had suspension rates above 5 fig 2 depicts the size suspensiondeletion rates and number of users classified as isis oec members within the 10 largest louvain groups 38 in our weighted directed network m we determined excessively high suspension rates within clusters 4 and 6 to be consistent with isis support although these clusters contained isis oec members modularity based clustering algorithms like blondel et al 38 did not provide enough information to distinguish between isis oec members and other user types there were still many official and nonisis supporting accounts in each of the clusters with elevated suspensiondeletion levels and manual sampling indicated that isis oec members existed in clusters without high suspension rates as well however community optimization provided enough context for us to reasonable use the union of suspendeddeleted users in louvain clusters 4 and 6 in m as labelled isis oec member cases for vertex classification community optimization also helped us identify the need to systematically remove official accounts we constructed a feature set using spectral representations of the f rec m rec and h user×usersharedhashtag networks as described in section 2 a full list and description of our feature set is included in table 2 as will be highlighted in section 4 the isis oec is highly interested in the ongoing operations in northern iraq and syria as such they discuss political figures and news sources extensively initial attempts to detect the isis oec contained many official accounts as previously defined therefore in our first iteration of multiplex vertex classification the task was to remove all official celebrity and news media accounts to do so we conduct an iteration of ivcc by developing a training set of positive and negative examples of official accounts to apply to the rest of our dataset our positive case labels for official accounts consisted of 2144 known celebrities politicians and journalists as well as an additional 873 accounts with more than 150000 followers we labelled the 8356 suspended deleted accounts in our dataset as nonofficial accounts and trained a random forest classifier 55 the random forest classifier is an ensemble method that constructs a multitude of decision trees and uses the mode of these classes to correct for the problem of overfitting associated with many tree based classifiers we found its performance to be significantly better than svm with respect to accuracy when identifying official accounts to remove from our dataset the classifiers superior performance was likely due to the various types of official accounts creating contingencies better captured by a tree based classifier it is worth mentioning that we are not interested in using this classifier on accounts not contained in g so we conduct use a traintest split but also use random sampling to assess accuracy the resultant classifier yielded accuracy of 913 and an f1 score of 758 on these heuristically labeled examples our post prediction sampling yielded no significant difference with blind classification of 50 randomly selected accounts the classifier identified an additional 7140 newscelebrityofficial accounts which we removed from g to form g once we were confident that a high percentage of official accounts were removed we conduct an iteration of mvc to identify isis oec members for this task we train a support vector machine classifier similar to those presented in 41 again we labeled the 5126 accounts marked as suspendeddeleted and grouped in louvain clusters 4 and 6 of the m network isis oec members we then randomly sampled 10000 active accounts in louvain groups 34 and 7 in the f network and labelled them as nonisis supporting the resultant classifier identified 18335 isis oec members we then combine the classified 18335 vertices with our 5126 labelled vertices and construct a t with our network of suspected isis oec membersa t we conduct community optimization and network analysis in section 4 summary statistics of a t are provided in table 3 we acknowledge that our positive case training instances contain uncertainty as twitter suspends accounts for a variety of reasons we will address this issue and discuss our efforts to validate model output in detail if the following section performance and validation in this section we will present our results first for the models performance on our training data set and then we will discuss additional manual validation efforts using our predictions multiplex vertex classification extends current methods by applying a combination of the findings developed in 43 and 41 given a large multiplex network with annotated vertices we are able to accurately identify our targeted community isis oec members we compare mvc to 43 and 41 by constructing three feature sets • θ mnvc represents the present work and consists of user account features and spectral and node metric representations of the following mention and user by user networks • θ sociodim represents 41 and consists of user account features and a spectral representation of the mention network • θ pmm represents principal modularity maximization as presented in 43 pmm utilizes eigenspace representations of the following mention and user by user networks for this feature set we used the largest two eigenvectors of each of the respective networks and subsequently performed canonical correlations to maximize the correlations between each networks respective eigenspaces a detailed description of each feature set is provided in table 2 table 4 illustrates mnvcs superior performance across all performance metrics accuracy is simply defined as the proportion of correctly classified cases in our test set precision is the percentage of positively classified cases that were actually positive recall measures the percentage of positive cases that were classified positive finally the f1 score 56 estimates accuracy by adjusting for bias associated with skewed class distribution it is important for us to reiterate that our measures of performance in this section quantify how well our classifier was able to differentiate classes in our training data we acknowledge that we have made assumptions to develop our positive case training instances that could reduce precision when applied to unlabeled data therefore an f1 score of 96 does not necessarily imply that approximately 96 of the users we predict are true isissupporting oec members table 3 depicts a t the suspected isis oec member network identified in section 4 each network is more dense than its parent network in g however we have taken measures to validate model output manually as will be explained at the end of this section we see that mnvc outperforms both sociodim and pmm with respect to each metric although our classifiers performance is relatively high with approximately 22000 accounts classified as isis oec members we would expect more than 900 accounts to be falsely labeled as isis oec members we will discuss the application of these methods in detail in section 6 however a 4 false positive rate and the varying degrees of support observed among passive sympathizers again imply these methods would best serve as a means to study online populations that appear vulnerable to online extremism metric network a f a frec a m a mrec with respect to our official account classifier mnvc and sociodim performed almost identically we hypothesize that this is likely due to the heterogeneous nature of official accounts we used this classifier to remove accounts belonging to celebrities news media corporations ngos and governmental organizations thus the positive class likely had many contingencies associated with it and would be more well suited to a tree based classifier like the random forest algorithm explained in section 2 our use of twitter suspension rates within specific user groups as positive case labels introduces uncertainty as there are many reasons for twitter to suspend accounts to address these limitations we took several steps to assess the accuracy of our heuristics this included discussions with native language speakers and blind sampling of accounts predicted as isis oec members further our analysis indicated the isis classifier generalizes to unlabeled data in ways that would not suggest biases from our networkbased and suspensiondeletionbased heuristics many of the accounts labeled by our classifier post content that is barbaric and in clear violation of the twitter rules precluding the use of the service to promote violence 13 there are other predicted isis oec members whose content does not clearly violate twitters policies and would generally be considered free speech however these users content is still consistent with the description of passive supporters presented in 91012 finally in light of twitters continued aggressive program to remove extremist content from its site 57 we performed an additional check of suspension rates in january 2017 we found suspension rates of 39 7 and 4 for our predicted classes of isissupporting nonisissupporting and official accounts respectively although these suspension rates do not conclusively prove any account predicted as an oec member to be an isissupporter they do imply that our methodology identifies communities containing sizable pockets of extremism we have in this section therefore performed a variety of checks to ensure that our classifier is able to identify members of the isis oec in ways that outperform other relevant approaches as we have noted there is no way good to assess ground truth with pure certainty in our setting thus leading to some uncertainty in our validation efforts however this uncertainty should be considered in the context of many other related tasks in social media mining and natural language processing where the quality of annotation has recently been questioned 5859 even on tasks as seemingly straightforward as dependency parsing 60 while analyses of performance are imperfect here we have tried in various ways to address them making our efforts as stringent if not more so than much related work future efforts are needed across the field as a whole in order to better understand how to address these outstanding issues case study the isissupporting oec the challenge of drawing useful intelligence analyses from social media remains an open research problem but oec detection offers new opportunities for intelligence and strategic communications experts to gain needed understanding into large populations susceptible to extremism the following subsection is intended to provide illustrative intelligence analyses offered by oec detection the left panel in fig 3 depicts the isis supporting reciprocal mention network a mrec where color indicates louvain grouping language drives the most clear division among internetwork communities and is highlighted in the middle panel we used langid as introduced in 61 to identify language at the user level blue vertices indicate users whose tweet streams identified as arabic with probability in excess of 90 while green vertices depict users whose tweet streams identified as english with probability in excess of 90 yellow vertices indicate users whose tweets contain a mixture of english and arabic a small portion of those users contained mixed language patterns to include turkish and russian for the most part however these users form a bridge between the arabic speaking and nonarabic speaking communities in the isis supporting network interesting structure also exists within the arabic speaking portion of the community the relatively small cluster to the far right of the arabic speaking portion of the community represented by yellow vertices in the left panel consisted of accounts sharing lectures and videos on muslim theology while the majority of these accounts did not overtly promote jihad or support isis it is interesting to highlight that their follower counts often contained hundreds or thousands of isis oec members an example of one such account belongs to dr hani alsibai who has been cited by ansar alsharia as one of five influential thinkers from whom the terrorists in tunisia obtain their encouragement 62 at this time we are unable to determine to what degree these accounts provide active support or if their followers simply present a fertile recruiting landscape for isis propagandists it also appears that some propagandist accounts use bots to gain stronger influence the red and blue groups depicted in the left panel of fig 4 are visible examples of what we believe to be bots in our dataset we believe these to be bots because in each case the groups represent a fully connected subgroup where each account repeatedly mentions all other members of the group as well as a parent account or accounts although relatively few accounts exhibit this group structure we hypothesize they are used to elevate the relative popularity of the associated parent accounts and remove them for subsequent analysis fig 4 highlights changes in user activity with respect to time the left panel depicts isis supporting users where the xaxis details the account creation date and the yaxis gives the average number of tweets per day for the life of the account color indicates the suspension status of the account where a black circle indicates the account remains active while red indicates the account has been deleted or suspended the right panel depicts a time series of the tweet stream of 10000 randomly sampled isis supporting users each time series has a high level of transparency to illustrate the distribution of daily user activity over time the red line depicts the cumulative distribution function of account creation dates within the isis supporting network the plot highlights the creation of many isis supporting accounts providing a high volume of tweets in the fall of 2014 in particular the large number of high tweet volume accounts introduced in early october 2014 were likely bots though the left panel clearly highlights twitters ability to identify and suspend these accounts their effect is clearly seen in the right panel and this highlights the groups use of bots to possibly generate recruits andor inflate the perception of their appeal beyond understandings of the group structure and tweet time series the role and relative importance of users within the observed social network network are of interest to gain insight into this we rely on two link types within our dataset mention and following ties reciprocity has been shown to be a strong indicator of trust within online social networks 44 45 46 and reciprocal mention ties provided the most information gain with respect to our isis supporting classifier comention ties also provide strong indicators of core membership within our isis supporting network both betweenness and degree centrality quantify how trusted a user is among other members of the network but trust alone does not identify core members or help distinguish roles to account for this we construct the following metric which quantifies the proportion of a users following ties that are members of our isis supporting network a we refer to this metric as isis focus and use it as a proxy for the users ideological affiliation with isis isis focus ¼ f isis supporting f totalð2þ fig 5 depicts the bivariate distribution of users classified as isis supporting with respect to degree centrality within the reciprocal mention network and isis focus the dashed black lines depict the median values of the two respective metrics dividing the plot into four quadrants though the quadrants depicted in fig 5 do not represent finite delineations with respect to user role type we find that both metrics provide useful information when identifying core members users with high degree centrality and high isis focus are powerful disseminators of isis message these are often accounts of popular fighters accounts designed to look like legitimate news media or simply popular isis propagandists those with high isis focus and low degree centrality represent similar accounts but with less popularity they appear to have ideals almost identical to those in quadrant i but are either less skilled at generating a following or relatively new to the network we also expect recruits to be more likely identified in quadrant ii accounts with high degree centrality and low isis focus are highly trusted but not as highly affiliated with isis this quadrant contained accounts that did not overtly support isis but provide information highly relevant to core members like regional news media and islamic sermons and educational material additionally there were users who appeared loyal to other jihadist groups such as jabhat al nusra or ahrar al sham or other popular causes in the region such as charities associated with gaza finally users with relatively low scores in both metrics represent passive observers these measures are important in that we can use these measures to prioritize additional searches of the twitter api that is for those users we identified in step 2 of our sample we have not collected accounts from all of their following ties and can now use a combination of these metrics to prioritize which accounts to download removing nonisis supporting accounts also enables us to understand the topical interests of isis oec members and how they evolve over time such analysis is critical to gain understanding and counter isis narrative and its ability to generates resources we quantify both the frequency of various hashtags as well as the number of distinct actors using them this enables us to identify what topics have the broadest appeal as well as topics that might be the result of a small set of highly active users frequencies inflated by a relatively small highly active group of users a closer look at hashtag 1 is translated tweet mentions of allah and is associated with a twitter application that offers to mention god every hour on a users timeline the hashtag is used over 100000 times but by a relatively small set of 1648 users of these tweets 75382 are posted by only 100 users who all seem to retweet one anothers verses from the quran and hadith as well as unique isis related content from the battlefield in other words these hashtags are used by high volume tweeting users to systematically link the groups theology with battlefield exploits we postulate that this type of analysis could also identify key mouthpieces or propagandists in the network more broadly we can identify the most unifying and energizing topics of the network by looking at how the most broadly used hashtags change over time fig 7 depicts the top 100 nonarabic hashtags in terms of number of unique isis supporting users the yaxis depicts the seven day moving average of the respective hashtags frequency over time nonarabic hashtags with a moving average that reach above 500 tweets per day at any given time period are labelled many of the popular hashtags confirm things we already know about the isis supporting movement isis oec members focus on events relating to sunni conflict in the greater mena region and the temporal peaks in fig 7 reflect those interests however some of these hashtags offer novel insight for example the popularity of helparakan referring to a state in burma is consistent with the isis study groups assertion that expansion into south eastern asia is one of isis strategic objectives 63 the trending hashtag ei refers to letats islamic and highlights the networks interest in mehdi nenmouche a french jihadists arrest and pending extradition to belgium in june of 2014 64 identifying these topics of interest and the influential users tweeting about them could provide useful understanding of the groups marketing objectives and help drive intervention strategies societal implications and methodological limitations the responsible use of social media intelligence and its relationship to individual privacy in democratic states is an important open question for policy makers 196566 to this end we acknowledge that our methods could be unethically employed to identify political opposition or dissidents indeed our classifiers that did not incorporate analysis of hashtags routinely identified online activism related to a variety of causes consequently we join walsh et al in their advocation of patient nuanced political dialog with respect to developing open source intelligence policy in western democracies 19 this policy debate centers around both social media users reasonable expectation of privacy and the ethical implications of mining their online content with respect to the latter the ethical implications of mining online content using our method vary based on the intended use of the method we have envisioned here two use cases for ivcc first and most importantly as western governments have started to search for diplomatic means to counter extremist propaganda ivcc can be as a means to gain understanding of online populations vulnerable to extremism we believe this to be an ethical use of the method as the primary intention is to reduce the likelihood of an individual being deceptively coerced into an extreme ideology a second use case of ivcc would be for intelligence collection this use case certainly could require more restrictive policy depending to intelligence category with respect to the former element of policy debate it is without question that users reasonable expectation of privacy must be kept in mind at all times a common argument against doing so is that social media users have the ability to privatize their accounts or to not use the media at all however these options are often not tenable further although many users understand their online behavior is used for marketing purposes they may not be comfortable with their behavior being used to inform diplomacy or military operations indeed one could assume users would not consent to the use of their information for intelligence collection this distinction between marketing versus intelligence objectives in an important one particularly in light of the mission statement for the newly formed united states department of states center for global engagement the state department is revamping its counterviolentextremist communications efforts through a new global engagement center this center will more effectively coordinate integrate and synchronize messaging to foreign audiences that undermines the disinformation espoused by violent extremist groups including isil and alqaeda and that offers positive alternatives the center will focus more on empowering and enabling partners governmental and nongovernmental who are able to speak out against these groups and provide an alternative to isils nihilistic vision to that end the center will offer services ranging from planning thematic social media campaigns to providing factual information that countersdisinformation to building capacity for third parties to effectively utilize social media to research and evaluation 67 for objectives similar to those listed above the use of ivcc by government agencies would therefore be subject to similar protocols to those used for behavioral research by institutional review boards these protocols include a strong push for deidentificationour methods make no attempt to bind online and offline identities and agencies using these methods to inform messaging efforts could do so with deidentified data while we acknowledge that the use of bulk deidentified metadata has been the subject of concern 19 this issue is routinely encountered by irbs in academia as well further within a context of informed diplomatic messaging the use of ivcc is thus proximal to academic research and further analogous to individually tailored online marketing ethical employment of our methods could be carried out to understand vulnerable online populations and ultimately preserve civil liberties peacetime military information operations aimed at messaging to specific populations could be viewed similarly 68 and implemented with deidentified data the complexity of these issues requires a substantive theoretical framework under which to characterize these various ethnical concerns walsh et al who provide a framework with which to balance the importance of civil liberties with national security in an intelligence context 19 their framework is based on the collection method context and target in our case social media mining would be our method however the increasingly complex combinations of context and target imply the need for nuanced policy currently policy has started to address the varying expectations of privacy in wartime peacetime and counterterrorism contexts however the onset hybrid warfare that is conducted by state and nonstate actors purposely beneath the threshold of western military intervention 69 further complicates policy development the intelligence target also has policy implications specifically the purpose and category of the desired intelligence product needs to be considered for the purpose of describing a commanders operating environment or assessing ongoing operations authorities could be quite liberal intelligence used to develop military targets or bind online and offline identity would imply more restrictive policy as stated by walsh et al the increasingly complex nature of conflict call for patient political dialogue and policy makers need to take their citizens with them when making arguments for new policy and authorities 19 in sum implementation of ivcc for social media intelligence does on the one hand require a more formal framework and more nuanced discussion on the other hand however it is clear that the method can also be used in many ethical fashions and to improve efforts of national security conclusion the present work makes two major contributions to the literature first we develop iterative vertex clustering and classification a scalable annotated network analytic approach for extremist community detection in social media our approach outperforms two existing approaches on a classification task of identifying isis supporting users by a significant margin second we provided an illustrative case study of the isis supporting network on twitter to the best of our knowledge it is the most comprehensive study of this network and it provides a variety of important insights that may prove important in better understanding the incredible proliferation of isis propaganda on twitter most notably we find that • leveraging the multiplex and multinode structures available in twitter data significantly improved our algorithms ability to accurately identify isis oec members on twitter • identifying and isolating large portions of an online extremist community offers unique insights into the groups ideology and influence and helps identify key users and roles • ivcc offers promise for making online extremist community detection in social media a practical reality to inform both diplomacy and defense initiatives this case study offers a unique opportunity to infer positively labelled cases based on twitter suspensions and clustering techniques however it is unlikely that such a large number of labeled cases would always be available thus implementations using semisupervised algorithms or active learning 70 would make ivcc more generalizable and should be a topic for future research ivcc is also limited in that it does not account for simultaneous group membership of users it is likely that there are jihadists that support various terrorist groups and allegiances can be dynamic ivcc does not provide probabilistic clustering or account for changes in group dynamics over time similar to 71 we would like to extend this methodology to an overlapping group framework to account for these types of users and also explore methods to identify temporal change points finally though preliminary results for ivcc as a methodology are encouraging they are limited in that we do not provide an empirical analysis of ivcc with respect to benchmark we will leave this analysis to future work due to the emphasis of this paper being the isis case study extremist community detection is an important need in processing social media and with such approaches like ivcc we hope that the influence of groups like isis can be counteracted in the near future deidentified edge lists and node attribute files are available at our project site projectsextremistcommunitydetectionphp as well as figshare plosonedataaccompaniesonlinethreat groupsupportingcommunitydetection uncoveringtheisissupportingcommunity ontwitter3166798

the islamic state of iraq and ashsham isis continues to use social media as an essential element of its campaign to motivate support on twitter isis unique ability to leverage unaffiliated sympathizers that simply retweet propaganda has been identified as a primary mechanism in their success in motivating both recruitment and lone wolf attacks the present work explores a large community of twitter users whose activity supports isis propaganda diffusion in varying degrees within this isis supporting community we observe a diverse range of actor types including fighters propagandists recruiters religious scholars and unaffiliated sympathizers the interaction between these users offers unique insight into the people and narratives critical to isis sustainment in their entirety we refer to this diverse set of users as an online extremist community or oec we present iterative vertex clustering and classification ivcc a scalable analytic approach for oec detection in annotated heterogeneous networks and provide an illustrative case study of an online community of over 22000 twitter users whose online behavior directly advocates support for isis or contibutes to the groups propaganda dissemination through retweets

introduction many studies have outlined a typical staged pattern of progression into polysubstance use whereby frequent and heavy alcohol and tobacco use precedes and increases the risk of subsequent cannabis use which in turn precedes the use of other illicit drugs 1 2 3 4 however the mechanisms underpinning this gateway effect remain contentious with ongoing debate focused on the meaning of the predictive associations between the stages of drug use and the extent to which these observed associations are causal 1 5 6 a range of studies have shown clearly that frequent and regular use of alcohol tobacco and cannabis is associated with increased risk of transition to other illicit drug use 124 especially among younger age cohorts 15 this sequence of drug use progression has been observed for 85 to 90 of prevalence and correlates of atypical patterns of drug use progression findings from the south african stress and health study polysubstance users in both developed125 and developing country settings 7 8 9 this pattern of drug use progression seems most characteristic of occasional drug users and may not be typical of regular and problematic users of illicit drugs 10 several studies of problematic drug users and highrisk youth in the usa found that significant proportions of participants violated this conventional sequence of drug use progression 6 11 12 13 14 these studies reported that a quarter to more than half of participants initiated cannabis use prior to using alcohol or tobacco and some started using other illicit drugs prior to using alcohol or cannabis 11 12 13 14 compared to individuals who followed the typical pattern of drug use progression violators of this pattern reported earlier initiation into illicit drug use greater lifetime drug use 11 13 14 a higher prevalence of early onset internalizing mental disorders15 were from different typically younger age cohorts 11 12 13 15 16 and came from more disadvantaged backgrounds characterized by high drug availability and greater poverty 61113 while these findings suggest that violations from the gateway pattern may be markers for progression to more serious drugrelated problems two recent studies using representative samples found that deviations from the gateway pattern were relatively uncommon and not predictive of later substance dependence 15 16 whether this is the case among south african drug using populations has not been fully explored at present little is known about patterns and correlates of drug use progression among south african samples this lack of knowledge potentially hampers the development of interventions that delay or halt drug use progression this paper aims to redress this gap by describing the prevalence and correlates of atypical patterns of drug use progression among a representative sample of south african drug users method data for the south africa stress and health study were collected between january 2002 and june 2004 from a national probability sample of 4351 adult south africans study sample the sample was selected using a threestage stratified and clustered area probability design 17 first a stratified sample of areas was selected from the 2001 south african census enumeration areas then a probability sample of housing units was selected from each ea third one adult respondent was randomly selected from the eligible persons in each sample housing unit field interviews were conducted with 4433 of the selected respondents due to quality concerns only 4351 of these interviews were retained for use in analysis ethical approval for this study was granted by the university of cape towns health research committee survey instrument the world health organisations composite international diagnostic interview version 30 was used to assess the presence of dsmiv disorders 18 the cidi is a structured layadministered interview that generates diagnoses according to the international classification of diseases 10th edition and dsmiv diagnostic systems 18 19 for this study the english version of the cidi was translated into several other south african languages by panels of bilingual and multilingual experts using iterative backtranslation procedures measures drug use all respondents were asked whether they had ever used a alcohol b tobacco c cannabis d other drugs or e extramedical drugs following a positive response to these questions the cidi druguse modules were administered to assess for the presence of lifetime and 12month substance use disorders and to obtain more information about druguse patterns including age of onset progression and problem severity other mental disorders other mental disorders assessed in this study included anxiety disorders mood disorders and impulse control disorders lifetime prevalence age of onset 12month prevalence and disorder severity for 12month cases were assessed for each disorder covariates this study included the following timefixed covariates sex raceethnicity and age timevarying covariates included residence completed level of education marital status employment family income and asset index for the latter 17 items that reflected individual and household wealth were used to construct a composite asset score which was categorised into low medium and high asset classes order of onset and gateway violations the onset order for each drug used was determined from retrospective ageofonset reports we defined gateway violations as the following • the use of cannabis prior to both alcohol and tobacco use • other drug use prior to both alcohol and tobacco use • extramedical drug use prior to both alcohol and tobacco use analysis procedures to account for the stratified multistage sample design data were weighted to adjust for differential probabilities of selection within households and for differential nonresponse a poststratification weight was used to make the sample distribution comparable to the distribution of the south african population in terms of age sex and province the weighting and geographic clustering of data were taken into account using the taylor series linearization method chisquare analyses were conducted to examine the bivariate associations between sociodemographic variables and gateway violations among users of each drug type for these analyses the reference group was the rest of the sample crude associations between gateway violators and lifetime dsmiv anxiety mood and substance disorders were generated using other drug users as the reference group for example the association between cannabis gateway violators and mental disorders was calculated with the reference group being all participants who had ever used cannabis results overall 122 of respondents initiated substance use in an order that violated the typical pattern of substance use progression the most common violation was initiation of extramedical drug use before alcohol and tobacco followed by cannabis use before the use of alcohol and tobacco respondents in the ≥ 50 years age group were the least likely to report illicit drug use before alcohol and tobacco extramedical drug use before alcohol and tobacco and any gateway violations compared to respondents in the three younger age groups among substance users violations of the normative pattern of drug use initiation were much more common among extramedical drug users and illicit drug users than cannabis users the violations were least common among alcohol and tobacco users table iii presents the results of bivariate analyses examining sociodemographic correlates of gateway violations gender was significantly associated with violations of each kind female respondents were significantly less likely than males to have used cannabis prior to using alcohol and tobacco and to have used other drugs prior to using alcohol and tobacco in contrast compared to male respondents female respondents had significantly greater odds of initiating extramedical drug use prior to alcohol and tobacco with women comprising almost twothirds of this subset of gateway violators although age was not significantly associated with the use of cannabis prior to the use of alcohol and tobacco or the use of other drugs prior to alcohol and tobacco respondents in the younger age groups comprised the bulk of these gateway violators age was significantly associated with the initiation of extramedical drug use prior to the use of alcohol and tobacco more specifically respondents between 1829 years of age were significantly more likely to use extramedical drugs out of the gateway sequence compared with respondents in the ≥ 50 years age category raceethnicity was unrelated to gateway violations of any kind education level and employment status were unrelated to the use of cannabis or extramedical drugs before alcohol and tobacco however these variables were associated with the precocious use of other drugs with respondents with higher levels of education and who were employed significantly more likely to report using other illicit drugs prior to alcohol and tobacco than respondents who were unemployed and less educated finally residing in an urban area and having a medium asset score was significantly associated with using cannabis before alcohol and tobacco but was not associated with the precocious use of other illicit drugs or extramedical drugs table iv presents the results of bivariate analyses examining associations between mental disorders and gateway violations the presence of any lifetime disorder was unrelated to the use of cannabis before alcohol and tobacco but significantly associated with the precocious use of both illicit and extramedical drugs both of these gateway violations were associated with a decreased likelihood of any type of lifetime mental disorder when associations between specific types of disorders and the three gateway violations were examined we found that lifetime mood and anxiety disorders were unrelated to gateway violations of any type in contrast the presence of any type of substance use disorder was associated with a significantly reduced likelihood of using illicit drugs prior to alcohol and tobacco or of using extramedical drugs before alcohol and tobacco specifically atypical patterns of use among extramedical drug users were associated with significantly less chance of having a lifetime alcohol use disorder discussion this study examined the order of onset of drug use and considered the possible impact of deviations from the typical sequence of drug use initiation on the risk of developing a substance use disorder using a representative sample of south african adults to our knowledge this study is the first of its kind to describe violations of the gateway pattern of drug use progression in africa more specifically we examined three atypical sequence of drug use progression the use of cannabis prior to the use of alcohol and tobacco other illicit drug use prior to the use of alcohol and tobacco and extramedical drug use before alcohol and tobacco in our study 122 of respondents reported atypical sequences of drug use progression while this proportion is relatively small it is more than double that reported in studies conducted in developing country contexts where deviations from the normative pattern of drug use typically ranged from 3 to 5 of the sample 15 16 in part this could be due to the fact that earlier studies did not consider extramedical drug use prior to the use of alcohol and tobacco as a violation of the gateway pattern of drug use progression while our examination of extramedical drug use violators significantly increased the overall proportion of respondents reporting an atypical sequence of drug use initiation the proportion of respondents reporting cannabis use prior to the use of alcohol and tobacco was also slightly higher than the proportion presented in earlier studies 15 16 the proportion of substance users reporting violations of the gateway order of drug use initiation was also much higher in this study compared to previous studies 15 our study found that more than half the extramedical and illicit drug users and roughly a third of cannabis users had atypical sequences of drug use progression taken together these findings suggest that the gateway pattern of drug use progression is not as common among south african substance users as previously thought one reason for this may lie in the increased availability of cannabis and other illicit drugs in south africa since 1994 20 among younger age cohorts who form the bulk of the cannabis and illicit drug gateway violators this increased availability may have translated into increased opportunities to use these substances at the same time tighter regulations around the sale and use of alcohol and tobacco may have discouraged young people from starting their drug use trajectories with these substances this explanation is supported by findings from studies conducted in other countries which report that opportunities to use substances and drug availability influence the order of drug use initiation and transitions to different types of drugs 19 however this explanation cannot fully account for the high proportion of respondents who reported the use of extramedical drugs before alcohol and tobacco in this study younger age cohorts were most likely to report extramedical drug use prior to the use of alcohol and tobacco global epidemiological trends in substance use might help explain this finding with recent studies reporting significant increases in extramedical drug use among young people across a range of countries 21 apart from these global trends the precocious use of these substances may also be driven by the fact that these substances are easy to obtain and their use is relatively less stigmatised than the use of alcohol tobacco or illicit substances in south africa 22 the important role that stigma may play in choice of first drug is also supported by our findings that female respondents were significantly more likely to report using extramedical drugs prior to alcohol and tobacco than their male counterparts and that men were much more likely to report the early use of cannabis and other illicit drugs compared to females compared to men womens use of alcohol tobacco and other substances is still highly stigmatised in south africa and is associated with a failure to fulfil a socially acceptable female role and sexual availability 23 for women in this country extramedical drugs may seem a socially acceptable alternative to alcohol and tobacco finally while other studies have suggested that deviations from the normative pattern of drug use initiation are associated with the early onset of mood or anxiety disorders 15 and that many individuals who deviate from the gateway pattern also have cooccurring mental health problems 11 12 13 this study found no significant associations between atypical patterns of drug use progression and the presence of mood or anxiety disorders in addition atypical patterns of drug use did not increase the odds of developing a substance use disorder this challenges previous views that gateway violators have relatively more severe drug and cooccurring mental health problems and are at greater risk for substance dependence 11 12 13 however this finding should be interpreted with some caution first this survey did not assess for a number of key dsmiv disorders such as impulse control disorders and psychotic disorders of particular concern is the exclusion of the conduct disorders as these disorders are strongly associated with increased risk for substance use especially among adolescents 24 in addition many of our violators were young and it is quite possible that they had not yet progressed to abusive or dependent drug use or other mental disorders this may have skewed our findings regarding associations between gateway violations and substance dependence our findings on multiple patterns of drug use progression have important implications for substance abuse prevention efforts in the country given large variations in the sequencing of drug use prevention efforts need to target common risk factors for the use of any substance instead of only attempting to prevent the use of the socalled gateway substances of alcohol tobacco and cannabis second substance abuse prevention initiatives that traditionally have focused on the use of alcohol tobacco and illicit drugs also need to address extramedical drug use third screening for the use of alcohol tobacco and other substances by mental health and other health care workers should also include questions on the inappropriate and problematic use of medicines health care workers should also be alerted to the high prevalence of extramedical drug use among young women despite these implications findings from this study should be interpreted with reference to several limitations first this crosssectional data set relied on recall to assess age of onset of substance use and patterns of drug use initiation this may have led to reporting errors however given limited differences between the various age cohorts in patterns of drug use initiation it is unlikely that recall bias greatly influenced this studys findings second although the sash study obtained a high response rate reporting errors on the substance use module of the cidi may have occurred it is possible that illicit drug use may have been underreported particularly as this is a stigmatised activity 24 finally our findings could have been skewed by the exclusion of homeless and institutionalised people from the study persons who find themselves homeless and institutionalised represent a particularly vulnerable population group with typically more severe substancerelated problems than the general population 25 these limitations highlight the need for future research on patterns of drug use progression in south africa and their associated mental health consequences to minimise concerns regarding the accuracy of retrospective data longitudinal prospective studies that track young people over time and allow researchers to unpack patterns of drug use progression are required such studies would also benefit from examining possible associations between other mental disorders not included in this study and drug use progression in addition qualitative research that provides detailed contextual information on factors associated with drug use progression would be useful for guiding the development of interventions to delay or halt this progression conclusion despite some limitations this is the first south african study to examine atypical sequences of drug use progression key findings include atypical patterns of drug use progression are more common than in other settings and particularly prevalent among extramedical and illicit drug users extramedical gateway violators are mostly young and female and compared to nonviolators violators of the normative pattern of drug use progression are not at greater risk for a mental disorder or a substance use disorder these findings are potentially valuable for guiding efforts to prevent or halt drug use progression across the country most importantly they suggest that common risk factors underpinning the initiation of substance use rather than particular drugs of abuse should be the target of prevention initiatives acknowledgements

objective atypical sequences of drug use progression are thought to have important implications for the development of substance dependence the extent to which this assumption holds for south african populations is unknown this paper attempts to address this gap by examining the prevalence and correlates of atypical patterns of drug progression among south africans method data on substance use and other mental health disorders from a nationally representative sample of 4351 south africans were analysed weighted cross tabulations were used to estimate prevalence and correlates of atypical patterns of drug use progression results overall 122 of the sample reported atypical patterns of drug use progression the most common violation was the use of extramedical drugs prior to alcohol and tobacco gender was significantly associated with atypical patterns of drug use with the risk pattern varying by the type of drug none of the anxiety or mood disorders were associated with atypical patterns of use atypical patterns of drug use were not associated with increased risk for a lifetime substance use disorder conclusion atypical patterns of drug use initiation seem more prevalent in south africa compared to other countries the early use of extramedical drugs is common especially among young women drug availability and social environmental factors may influence patterns of drug use the findings have important implications for prevention initiatives and future research

introduction the term ambient intelligence used in 1999 by the european unions information society technologies program advisory group 1 describes a vision where people will be surrounded by intelligent and intuitive interfaces embedded in everyday objects around us and an environment recognizing and responding to the presence of individuals in an invisible way ambient technologies rely upon transparent unobtrusive and intuitive interfaces closer to the way people think and feel than to the way machines operate ambient technologies aim to make computer systems more adapted to human needs one of the goals of ambient intelligence is to give individuals the possibility to express themselves more efficiently accurately and effortlessly 2 by invisibly capturing and tracking their preferences into profiles 3 hence the need for context aware applications to take into consideration notions such as privacy identity and social concepts such as trust 45 in the 1990s userfriendliness had become ubiquitous in software development human computer interfaces that had championed the concept was elevated to a taught discipline and a research field concerned with the design evaluation and implementation of interactive computing systems for human use the key idea was to create a pleasant helpful and friendly experience for humans accomplishing computer tasks design methodologies used heuristics and the guideline measurements were usability metrics such as navigation page load speed accessibility and content relevance development and pervasiveness of games social software and networks has highlighted the need for dynamic interpersonal communication and social interactions the concept that encapsulates these ideas is conviviality if userfriendliness is indeed mandatory for software usability and accessibility it is conviviality alone that can convey the social complexity that todays technology is striving for but what is really at stake in this political context the eu launched a spearhead research theme from 1998 to 2002 called société de linformation conviviale more commonly known as the information society technologies programme the purpose of this program was to promote user empowerment through accessibility of information to all with increased security and in the context of wider development of ambient intelligence and distributed systems unfortunately the english translation of société de linformation conviviale replaced convivial with the expression userfriendly how far is this a mistranslation does userfriendliness really convey what is inherent in conviviality this question of conviviality has recently become part of a debate which remains unquelled yet what is conviviality could it simply be creating a cordial atmosphere at a dinner party or good relations between friends is it a prism which refracts the pressures of modern society it has even burst onto the public scene through politiciansspeeches discussions on conviviality have fanned the flames of debates should conviviality be used to regulate how citizens interact to create stronger ties between them make them more dependent on each other should it be used as a tool to manipulate citizens this is all overstated what is however now undisputed is that there is more to conviviality than once thought in previous work we identify conviviality as a key concept necessary to web communities such as digital cities 6 while it has been simultaneously defined in the literature as individual freedom realized in personal interdependence rational and cooperative behavior and a normative instrument as we discuss in section 4 no model for conviviality has yet been proposed for computer science in 6 we raise the question whether social intelligence design could be used to designing convivial digital cities we first look at digital cities and identify from the point of view of a social intelligence design two main categories of digital cities public web sites and commercial web sites we also note the experimental qualities of digital cities second in 6 we analyze the concept of conviviality for social science multiagent systems and intelligent interface we show the distinction among various kinds of use of conviviality the positive outcomes such as social cohesion trust and participation but also the negative aspects that emerged when conviviality became an instrument of power relations third we look at the normative aspect of conviviality as described in the literature and find that social norms for conviviality parallel legal and institutional norms for digital cities finally as an initial step towards obtaining measures for conviviality we present a case study describing interactions between agents and user using dependence graphs we also present an analysis of conviviality requirements and describe a plan and methodology for designing convivial digital the computer journal 2009 convivial ambient technologies 3 cities moreover in 7 we import the concept of conviviality to web communities by raising the question of what is distinct in computer science and what is the challenge of conviviality in computer science in this paper we further develop this vision we are interested in the following research question how to use the social concept of conviviality to develop userfriendly ambient intelligence applications to make this paper selfcontained we also summarize and reconsider some of the issues discussed in 67 our overall research question therefore breaks down into the following research questions what is conviviality what kinds of conviviality exist which conviviality requirements are relevant for computer science in general and ambient intelligence in particular which issues are relevant when developing convivial ambient intelligence which conviviality ontology should we use for ambient intelligence how to design convivial ambient intelligence applications how can the positive aspects of conviviality be used for ambient intelligence how should the negative aspects of conviviality be taken into account to ground our use of conviviality in computer science we have to understand the range of meanings and uses of the concept conviviality in the social sciences and we therefore start with a literature survey we distinguish between kinds of conviviality by distinguishing positive and negative aspects of the concept conviviality is usually considered a positive concept related to sociability however further analysis reveals a negative side related to ethical issues to study the relevance of conviviality requirements we first ask why applications should be userfriendly or convivial and then we ask why the concept should be used to develop ambient intelligence applications we argue that conviviality requirements for ambient intelligence are challenging because ambient intelligence artifacts give rise to a new virtual and social reality and conviviality issues play a central role in applications that are concerned with the interaction of material virtual and social realities conviviality highlights an important challenge that we illustrate with examples that emphasize ethical issues such as privacy threats surveillance of users and identity theft intelligent interfaces for example allow instant interactions and thereby create strong needs for coordination and regulation mechanisms that have to be addressed to ensure the safeguard of individuals against abuses such as privacy intrusions and identity manipulations to define a conviviality ontology and operationalize the concept of conviviality we relate the concept of conviviality to concepts of dependence we propose a conviviality ontology by operationalizing the fuzzy concept of conviviality such that it can be used in computer science in the same way as other social concepts like service contract or trust are used conviviality is defined using dependence networks and tools for conviviality are based on what we call conviviality masks to define tools for conviviality we define conviviality masks as a transformation of social dependencies by hiding power relations and social structures to facilitate social interactions we propose a design methodology to design convivial ambient intelligence applications using our operationalized concept of conviviality we consider our research questions answered when we have convinced developers of ambient technologies that conviviality may be a useful concept for ambient intelligence which can be operationalized in requirement analysis used in modeling languages and applied in design however we do not consider the validation of our approach in this paper but leave it to further research this paper is best seen as a proposal for a research program consisting of the development of languages for requirements analysis languages for ontologies and methodologies for design however since we aim to convince technology developers this does not mean that we restrict ourselves to an abstract conceptual or philosophical analysis but we make our proposal concrete and illustrate it with a futuristic but realistic example we illustrate our arguments and contributions with a running example on the use of ambient technologies in digital cities as a prototypical example where material reality such as ambient technologies interact with virtual and social realities for example in a digital city that integrates the virtual world with the real world people may walk around in the real city with pdas and leave notes in the virtual world many if not all future application usecases are a combination of the real and virtual world for example besides leaving notes about the real world in the virtual world people now use real money to buy property in second life and real university lectures are given in sl therefore we use the digital city example as a paradigmatic example for these future usecases our motivation is the inventing communities of communication project initiated by the university of luxembourg in april 2006 the city of luxembourg acting as a copartner provides us with usecases and is a test bed for our research the city project is to transform its current city web site into a centralized online administration the ecity fully integrated with eluxembourg the state portal city goals are provide citizens and visitors with electronic services to communicate with their administration while giving online access to solve administrative requests such as change of address and formal documents surrounding child birth the development of such digital cities is part of the eeurope strategy as first defined in lisbon in 2000 the layout of this paper is as follows in section 2 we address the use of social concepts in computer science in section 3 we introduce the running example of ambient intelligence in digital cities in section 4 we present a historical overview on the concept conviviality in section 5 we discuss the relevance of the concept for requirements for computer science systems in p caire and l van der torre general and ambient intelligence applications in particular in section 6 we discuss which definition of conviviality can be used and operationalized in ontologies to model ambient intelligence applications and in particular how the concept of conviviality is related to other concepts in section 7 we consider the design of convivial ambient intelligence applications social concepts in computer science a social concept like conviviality can be used in ambient intelligence in various ways consider the following examples informal requirements of decision makers our system should be convivial and easy to use of users i want to interact with a convivial system populated by other users who make me feel welcome formal concept in an ontology for modeling ambient systems system a is convivial whereas system b is efficient performance measures the conviviality is 87 on a scale from 0 to 100 programming constructs if use 10 then conviviality though the latter ones may seem farfetched at the moment many other social concepts have been adopted by computer science at all these different levels from concepts in informal requirements via modeling concepts in uml to programming constructs for example mainstream computer science nowadays involves social concepts like services contracts and coordination at all of these levels some of these social concepts have been adopted by ambient intelligence too though this area seems to be suited for other social concepts from the mainstream ones in this section we give some examples of existing social concepts in computer science to study the kind of applications we may consider for the conviviality concept in ambient intelligence we do not attempt to be complete business informatics business informatics is an interdisciplinary discipline using many concepts from other disciplines for example architecture is defined as the fundamental organization of a system embodied in its components their relationships to each other and to the environment and the principles guiding its design and evolution the recent standard called ieee 14712000 8 emphasizes that views on the architecture should always be considered in the context of the viewpoint of a stakeholder with a particular concern a system is a collection of components organized to accomplish a specific function or set of functions a systems stakeholder is an individual team or organization with interests in or concerns relative to a system a view is a representation of a whole system from the perspective of a related set of concerns a viewpoint is a specification of the conventions for constructing and using a view it is a pattern or template from which to develop individual views by establishing the purposes and audience for a view and the techniques for its creation and analysis another example is the term value in economics values are related to the preferences of a decision maker value networks model the creation distribution and consumption of economic value in a network of multiple enterprises and endconsumers this leads to the definition of obligations of the actors and ways to deal with violations to ensure that actors behave according to the value network model finally control procedures and protocols are added to ensure that obligations are fulfilled or violations sanctioned note that these issues appear to be different from traditional issues studied in computer security such as cryptography also traditional formalisms of for example authorization and authentification such as the popular ban logics 9 focus on issues such as public key infrastructures instead of formal models of contracts the concept of privacy and data protection are viewed as complementary and interdependent both tend to preserve individuals from excessive constraints and influences different facets of personal privacy can be distinguished depending on motives and ambient intelligence technologies two important parameters relating to privacy the ability to monitor eg surveillance and the power to search and combine information bits 10 in the ambient intelligence context techniques devised for privacy protection policies must be flexible three main requirements have been identified to reach this goal formal specification of privacy policies trust management and auditability eg a posteriori measures 11 mas another interdisciplinary area is mas concepts models and theories from the social sciences are studied in mas to regulate or control interactions among agents 12 as a theoretical basis for the development of socalled social software 13 and to develop mas for computational social science 14 examples of social concepts studied in mas are societies coalitions organizations institutions norms power and trust 15 considering the notion of dependencies it is noted that values and preferences lead to dependencies among actors when the actors have limited or bounded resources for example dependencies among enterprises explain why and how they create distribute and consume economic value this leads to a second topology besides the topology of the network over which values are exchanged there is also the topology of the dependency network the value network and the dependency network are clearly related as value exchanges are motivated by dependencies and change the dependencies serviceoriented computing service is a concept from business economics which has been used in computer science in serviceoriented architectures and in web services not only business processes but also computer applications are modeled as service providers an advantage of services is that complex services can be offered as a bundle of simpler services for example the service of a travel agency to organize a holiday trip may consist of services to book a flight and make reservations for a hotel and theater complex services can be designed in a compositional way by first designing the simpler services and then composing them into a complex service the notion of contract has been introduced in software engineering in meyers 16 17 18 design by contract which is a wellknown software design methodology that views software construction as based on contracts between clients and suppliers relying on mutual obligations and benefits made explicit by assertions it has been developed in the context of objectoriented programming it is the basis of the programming language eiffel and it is well suited to design componentbased and agent systems the advantage of the methodology is that it clearly defines the interaction between callers and routines in terms of their interfaces however there is still a gap between this methodology and formal tools supporting it for example dealing with contract violations is realized by exception handlers whereas it is well known in the area of deontic logic in computer science 19 that violations and exceptions are distinct concepts that should not be confused service contract combines the two concepts again the interaction between caller and routines is defined in terms of mutual obligations and benefits but this time the notion of contract has been extended with the concept of servicelevel agreements the service level describes the quality level of the service however formal coordination techniques have focused on the coordination of the contract protocol and have paid less attention to the quality of service the problem is that the qos is a value instead of just information and values have properties less easily captured by computer science formalisms quality is defined as the control mechanism for resource reservations qos guarantees a level of performance such as bit rate delays and the packet dropping probability to a data flow the perceived qos is also called the quality of experience and is an important measure for the design of ambient intelligent systems as it captures from the users point of view the endtoend performance at the service level to make users experience seamless users should be able to perform their tasks without interruptions even though resources and device types and locations are constantly changing moreover they should be able to use all accessible resources within runtime ubiquitous computing environments with maximum efficiency while taking into account possible threats and the demands for quality of protection 20 21 22 coordination is emerging as an interdisciplinary concept to deal with the complexity of compositionality and interaction compositionality is a central concept in computer science for which many models and tools have been developed including coordination languages which are also applied to the composition of services they can successfully model the interaction between services but they are less successful in decomposing the quality of a composed service into terms of the qualities of the services it consists of and more generally they are less successful in splitting up a servicelevel agreement of a composed service in to servicelevel agreements of partial services there are many definitions of coordination for example coordination has been defined in management science as the management of dependencies among independent activities 23 in agent theory as the process by which an agent reasons about its local actions and the actions of others to try to ensure the community acts in a coherent manner 24 in social theory as the activity that involves the selection ordering and communication of the results of agent activities as that an agent works effectively in a group setting 25 or as a process in which agents engage in order to ensure a community of individual agents acts in a coherent manner 26 in computational intelligence as a way of adapting to the environment 27 and in computer science as the study of the dynamic topologies of interactions among interaction machines and the construction of protocols that ensure wellbehavedness 28 coordination languages models and systems constitute a recent field of study in programming and software systems with the goal of finding solutions to the problem of managing the interaction among concurrent programs as such coordination focuses on patterns that specifically deal with interaction it has mainly been applied for coordinating data streams but it can also be used for other coordination tasks summary sociocognitive concepts are used in various areas of computer science in a variety of ways both in interdisciplinary areas like business informatics or mas as well as in more traditional areas of computer science like software engineering such social concepts get a more precise and computational interpretation which may differ from the interpretation in its original discipline if conviviality is to be added to this list we need to develop concrete tools or techniques for incorporating measuring or predicting the emergent conviviality running example ambient intelligence in digital cities in this section we introduce the context of the research on digital cities then we introduce our running example where ambient intelligence applications are used in digital city and finally we p caire and l van der torre discuss how this running example is a prototypical instance of a much larger class of examples where the material world meets the virtual and social worlds digital cities one can argue whether they are for the better or the worse but what is certain is that since their inception digital cities have continuously been evolving this of course makes it difficult to define what digital cities really are in short digital cities are web portals that use the metaphor of the real physical city to provide virtual information spaces as a result there are many different kinds of digital cities depending upon the proportion between the political economic and social activities provided to users social virtual worlds such as sl and the habbo hotel are a growing form of digital cities they originally provided a communication medium to their users primarily to conduct social experiences through role playing it offers users the opportunity to experiment with new forms of solving problems and coordinating social life according to den besselaar et al 29 however the size and vitality of these massive multiplayer communities has recently attracted advertisers and businesses that are now adapting their professional services to these virtual communities therefore activities on these portals that were predominantly social and to a lesser extent economic and political today tend to have increasing economic activities is this a threat for other digital cities commercial portals certainly have to react to this menacing evolution ecommerce portals such as msn citysearch and aol digital cities traditionally offer commercial services shopping entertainment and more generally local easy to find and search information they provide practical resources for the organization of everyday life and support local economic activities the purpose of these digital cities is predominantly economic and to a lesser extent social and political however to compete with the menacing success of social virtual worlds they now develop social network activities such as yahoo 360 degree photo sharing site and google terra nova 3d virtual worlds frontiers are getting blurred that also goes for official administrations and countries the third kind of digital cities the eadministrations ecities and egovernments such as eluxembourg and digital shanghai these official portals of cities and countries provide useful tools to both administrations and citizens the purposes are not only to improve administrative efficiency and accessibility but also local democracy social cohesion and participation in elections these digital cities provide local social information infrastructures over the real city with public and administrative services to citizens and visitors although initially topdown organizations they now try to balance their activities with grassroots initiatives such as forums and online live interactions of citizens to town meetings in usa for profit businesses and nonprofit organizations coexist and compete in eu the attempts are to coordinate administrations companies and citizens whereas in asia governmentdirected growth is pursued the activities in these digital cities are still predominantly political and to a lesser extent economic and social however distinctions are getting smaller for den besselaar et al 29 digital cities may become a tool that enables people to do things by mobilizing the available local resources using existing and emerging social networks moreover to gain new members and sustain loyalty of their member base commercial digital cities have to keep innovating members invest time and efforts to construct their avatars fill their calendars and elaborate vast social networks and communities of friends similarly to reach citizens and fulfill the mandates of politicians and administrators public digital cities have to enforce technological and social progress a prevalent idea is that public digital cities provide infrastructure for networking local communities and to promote social interaction among people who visit or reside in a city 30 furthermore to meet these goals many strategies are currently being used and more are being investigated in a word the success factors of digital cities consist in achieving participation of institutions and communities balancing the topdown direction needed for technical infrastructure and the grassroots initiatives necessary to insure citizens cohesion and finally in finding equilibrium between economic and civic motivations the goal is to transform modernize and improve the level and quality of life of the population at both individual and community levels 31 ultimately digital cities need to deal with the same complexity as real cities to attract and retain usage and to function as entities that augment their physical counterparts one of the challenges linked to these success factors of digital cities is the connection between physical and digital cities this relation is one of the main topics of research in this field addressed such issues in the proceedings of digital cities 29 32 33 34 besides focusing on concepts such as edemocracy and conviviality referring then to qualities such as trust identity and privacy the vision of ambient intelligence is more directed towards physical than digital cities since the intelligent and intuitive interfaces embedded in everyday objects typically refers to physical objects it is only through the relation between the physical and virtual worlds that ambient intelligence plays a role in digital cities however whereas at this moment the virtual and physical worlds have limited interactions it is expected that they will be much more intertwined in the future to illustrate this growing trend we present several usecases of this interaction in the following section ambient technologies for digital cities in this section we introduce a number of usecases to illustrate how ambient intelligence pertains to digital cities these usecases are used in the remainder of the article to illustrate the role of conviviality in ambient technologies usecase 1 judy in paris judy just arrived in paris it is her first time in the city she is eager to find a quaint outdoor restaurant and settle down for a nice lunch her profile including a list of her favorite foods is memorized in her mobile phone her profile preference is set to a search distance of a five hundred meter radius the digital assistant brings up a selection of appropriate restaurants within that range and options to view video trailers of places judy selects her social networks to check the restaurants ratings she selects one of the restaurants and the digital assistant proposes ways to get there from this location additionally the assistant proposes a restaurant further away but offering special student discounts judy is a student a highpriority trait in her profile she selects the restaurant and her phone instantly brings up a map and the itinerary she would most enjoy to get there eg the customized option whenever possible walking through parks the assistant then signals the presence of digital notes in this area it displays an at a glance overview of the locationbased information space many digital notes are been left by other mobile users judy sets her phone to receive all notifications and start reading the notes while on her way to the restaurant at this particular location someone named arthur left information about this special tree planted two hundred years ago and further away an anonymous note mentions a historical event a few steps further someone nicknamed laura signals that a sale on sports clothes will occur in two hours in a nearby store she sends back a note asking if the store has mybrands clothes a few seconds later she receives an instant message from a store employee confirming it judy is thrilled she will be able to redeem the voucher for a mybrands shirt she won a few days ago at a raffle on the virtual world third life judy sends an sms to her friend kate to meet her virtually at the store in two hours to choose the shirt with her judy has now reached the restaurant definitely a popular place with students after lunch she sends a digital note from her current position to comment on the food and leaves for the clothing store usecase 2 harry in chinatown harry is going out to buy a gift for his neighbors party tonight i want to go to chinatown take the widest road asks harry to his cars digital assistant ok it will take about half an hour answers the assistant the assistant uses personalized information to do its automatic driving and parks the car in the hot spot area where harry will be able to pay his parking fee to the city directly from his mobile phone harry knows chinatown fairly well as every week he logs on to new york city 3d virtual city to play cards in a virtual club located in chinatown and usually prefers walking through the streets of little italy rather than being instantly teleported he is wearing his privacy jacket to shield himself from the street and other peoples wireless devices it secures his data and preferences harry sets his access to the friends and family option a few minutes later his mobile notifies him that his friend nick is close by who knows he may be able to get back the money he lent nick when he lost at the virtual card game last week nick meets him in front of the chinese gift store his wife carol owns a travel agency in sl business has taken a new turn since she started giving guided tours of sl islands to executives a real success carol and nick recently decided to adopt a virtual child to prepare for the future real family they want to have and nick is very excited he makes his debt payment to harry from his cell phone a direct electronic transfer from his bank account to harrys perfect for harry who right now really needed the extra cash additional usecases bob arrives late at a professional meeting upon his arrival the mobile devices of all other participants uploaded the pictures that were taken during the meeting bob will be able to instantaneously view the meeting pictures the key issue is to make sure that only the pictures of the meeting are uploaded nothing else particularly no personal pictures an analogous application for a group of tourists visiting a city is based on tour guides providing explanations about various buildings and events catherine is in amsterdam playing a virtual tennis game with her friend ted who is in paris catherine is an excellent player and ted often asks that exchanges be replayed in slow motion to learn from her anna who is american attends a conference in spain other attendees come from different countries and speak other languages all attendees are connected via mobile networks and languages are simultaneously translated into english for her with the mobile network supporting automatic interpretation technology locations and languages are no longer barriers to education virtual physical and social realities boella et al 35 distinguish virtual physical and social reality for ambient technologies for a user a successful experience is a seamless experience between the physical world he is actually in and the virtual world the ambient intelligence technology provides him with this raises the question of the relation between physical experiences and virtual experiences a further question is how these experiences relate to the social experiences users have while interacting with other users what are the differences and similarities between social experiences in the physical world and social experiences in the virtual world is conviviality different or the same distinction virtual and physical realities virtual reality is defined as an experience in which a human is surrounded by a threedimensional computer generated representation and is able to move around in the virtual world the computer journal 2009 p caire and l van der torre and see it from different angles to reach into it grab it and reshape it 36 the human is immersed in the virtual world depending on the technology used and interacts with it through graphic representations the digital virtual world can be a twoor threedimensional synthetic representation of a natural or imagined world that includes objects and representations of humans avatars or agents a typical example of a virtual world is sl in our running example 2 nicks wife carol has a travel agency in sl after logging on to her account she enters the virtual world and becomes her avatar for the other sl residents she is her avatar carol is both virtual reality and physical reality ambient intelligence is the opposite of virtual reality as the extension of ubiquitous computing ambient intelligence integrates microprocessors into everyday objects riva et al 37 p 19 observe that virtual reality puts people inside a computer generated world ami puts the computer inside the world to help usambient intelligence belongs to physical reality it creates contexts for humans to interact with themselves others and their environments in usecase 2 harry uses his virtual assistant to drive his car a more detailed view could show on the dashboard the threedimensional character interacting with harry using voice and capturing his voice and facial expression to regulate the driving just below the assistant a conventional user interface brings up additional information in a touchsensitive panel today one approach is to mix synthetic images and realworld data to transmit context information therefore blurring the differences between virtual reality and physical reality distinction physical reality and social reality for searle 38 p 153 the physical reality exists independently of our representation of it it is external to our system of representation to the world of nature physical particles and fields of force as our common sense idea leads us to believe physical reality exists outside of us and is available to all indeed how could people communicate with each other if physical reality was not publicly accessible reality hence physical reality does not depend on your or my representation it is expressed with brute facts to follow searles terminology in usecase 1 judy arrives in paris a city that exists independently of how judy or anyone else represents it paris has many features and facts such as restaurants and these brick and mortar constructions are brute facts in contrast the facts that a waiter serves judy a meal at certain listed prices and that she will pay with money that has value in the context of their society are institutional facts brute facts relate to physical reality and exist independently of any human institutions institutional facts relate to social reality and can exist only within human institutions summary social reality comes into our running example in two ways first the city is a social reality besides being the physical reality mentioned above in usecase 2 harry drives to chinatown parks his car and expects to pay a parking fee parking the car is a physical fact however having to pay a fee for leaving his car in a public place that has a parking meter is an institutional fact regulated by the city parking commission the parking meter counts as the fact that this space is owned by the city that applies this fee to raise taxes second ambient intelligence itself gives rise to a social reality in usecase 2 harrys parking fee can be paid by cell phone with call2park system this is part of the citys smart environment the city connects services and applications with ambient intelligence throughout the city to anticipate the nomadic behavior of citizens and facilitate their interactions searle 38 p 4 states that social reality is created by us for our purposes and seems as readily intelligible to us as those purposes themselves this directly applies to ambient intelligence social reality is modified by electronic devices that augment the possibilities of social interactions and influences the exchange and interpretation of information in the digital city ambient technologies depend on collective use and acceptance to become social realities they have a major impact on the city by their introduction of new social roles boella et al 35 develop an approach based on institutions to model the social structures that are being developed in ambient intelligence systems conviviality interestingly enough the eu was not the first to bring conviviality to the forefront a handful of scientists and philosophers had previously tackled the concept and shed some light on conviviality empathy and reciprocity were foregrounded by polanyi in 1964 furthermore putnam in 1988 considered conviviality as a condition for civil society a society with political equality civic engagement solidarity trust tolerance and a strong associative life all principles of a democratic society definitions of conviviality generally speaking a convivial place or group is one in which individuals are welcome and feel at ease 3941 but definitions in the literature spread from individual freedom realized in personal interdependence 42 to rational and cooperative behavior 43 to normative instrument 44 the definitions indicate that the meaning of conviviality depends on the context of use excerpts are presented in table 1 in sociology conviviality typically describes a relation between individuals and emphasizes positive values such as equality and community life for example in usecase 1 the conviviality of the system is in that anyone can leave a note for the benefit of anyone else in the community who want to access the notes however with power shifting between individuals and groups etymological and domain specific definitions 15th century convivial from latin convivere to live together with to eat together with french academy dictionary 45 adj convivial friendly and lively cheerfully sociable oxford english dictionary 46 technology quality pertaining to a software or hardware easy and pleasant to use and understand even for a beginner userfriendly usability by extension also reliable and efficient grand dictionnaire terminologique 47 sociology set of positive relations between the people and the groups that form a society with an emphasis on community life and equality rather than hierarchical functions grand dictionnaire terminologique 47 conviviality relations change minority and majority groups form outsiders are excluded and others force their way in this dynamic and temporal process raises questions such as how is conviviality created how does it evolve what makes it fail sadek et al 43 define conviviality as the essential and global characteristic of services … it emerges from the intelligence of the system and not from a set of local characteristics … that vary depending upon the application context and the types of users consequently a list of criteria will by itself not suffice additional critical factors to consider are the relations that bind the criteria together and the way these relations are perceived by individuals for example in usecase 1 judy enjoys social navigation while walking she reads the notes that others have left there and respond to them if she wishes they connect this activity makes her feel welcome as she is free to join in or not in the notes the dialog criteria are also respecting her privacy as she is not being assaulted by advertising and invaders the conviviality of the system is also in that she perceives the environment as being flexible to her moves and it allows her to respond to it at her will individuals versus groups in 1958 polanyi 48 is the first to use conviviality in a scientific and philosophical context he describes it as synonymous with empathy which alone can establish knowledge of other minds by allowing individuals to identify with each other empathy provides a way to acquire personal knowledge by experiencing the feelings thoughts and attitudes of an individual in 1974 polanyi 49 further describes a community as convivial when it aims at sharing knowledge members trust each other share commitments and interests and make mutual efforts to build conviviality and preserve it in usecase 1 the sharing of informative notes exchanged between visitors particularly illustrates this connection of minds that people establish through their annotated thoughts and concerns nature shopping or historical events in his 1971 critical discourse on education deschooling society 50 illich defines a convivial learning experience as one based on role swapping where the teacher role alternates with the learner role to emphasize the concept of reciprocity as a key component to conviviality in 1973 illichs tools for conviviality 42 brings a new dimension to the concept defined as an intrinsic ethical value indeed for illich conviviality means individual freedom realized in personal interdependence it is the foundation of a new society one that gives its members the means referred to as tools for achieving their personal goals a convivial society would be the result of social arrangements that guarantee for each member the most ample and free access to the tools of the community and limit this freedom only in favor of another members equal freedom when judy sends an sms to contact her friend kate she feels comfortable as kate is free to answer or not there is no pressure the technology allows for a convivial exchange that gives freedom to both judy and kate in the 1980s putnam and his colleagues further extend the concept of conviviality as an enhancement to social capital in 1988 they refer to conviviality as a condition for civil society 51 and in 2000 argue that in a civil society communities are characterized by political equality civic engagement solidarity trust tolerance and strong associative life 52 stressing the strong link between the performance of political institutions and the character of civil life for this reason the city that facilitates communication for its citizens and visitors for examples with free access to hot spots through the city allowing such exchanges as the payment of parking or social navigation through notes building on illichs learning webs skill exchange networks and peermatching communication concepts papert and harel 53 and the constructionists emphasize in 1991 learningbymaking and in 2001 sipitakiat 40 developed digital technologies for conviviality stressing the notion of equilibrium indeed over time group formation changes for example new members join the group while others leave or some new goals or rules are been added to keep its cohesion the group needs certain stability these notions of stability have been extensively studied in such fields as economics and game theory 5455 in a 2004 semiotics symposium on conviviality schechter 41 takes another look at the concept in a basic sense conviviality is a social form of human interaction the author binds interaction to physical experience and recognizes the social dimension of conviviality as a way to reinforce group cohesion through the recognition of common values thus the sharing of a certain kind of food andor drink can be seen as a way to create and reinforce a societal group through a positive feeling of togetherness on which the communitys awareness of its identity is based in usecase 1 judy goes to have lunch in the restaurant that gives a discount for students because it convivial for her to have a the computer journal 2009 p caire and l van der torre meal around likeminded people who have similar expectations about food style comfort and prices schechter transforms the physical experience of conviviality into a learning and knowledgesharing experience to know is to understand in a certain manner that can be shared by others who form with you a community of understanding it is worth noting that the conviviality values from a sociocognitive context such as social cohesion inclusiveness and participation by putting individuals at the center of change coincide with the very values praised by the ambient intelligence vision the darker side of conviviality a negative side of conviviality can however emerge when it becomes an instrument in the hands of power relations conviviality is achieved for the majority but only through a process by which nonconviviality is reinforced for the minority states ashby 56 who further denounces the instrumentalization of conviviality when one group is favored at the expense of another truth realities about minorities are built from the perspective of the majority via template token instances in which conflict is highlighted and resolution is achieved through minority assimilation to majority norms imagine that in usecase 1 derogatory jokes were left towards particular ethnic groups the system then may be convivial for the one laughing at the joke but not for the ones being laughed at conviviality masks the power relationships and social structures that govern communities argues taylor 44 she explores the contradiction between institution and conviviality asking whether it is possible for convivial institutions to exist other than by simply creating another set of power relationships and social orders that during the moment of involvement appear to allow free rein to individual expression …community members may experience a sense of conviviality which is deceptive and which disappears as soon as the members return to the alienation of their fragmented lives for example in usecase 1 we assume that the city administrators want to give a positive image of the city and remove any note that is not favorable without mentioning that the site is censured then even though the system installed by the city administrators seems convivial and open to all the fact is that it is only convivial for those who are in line with the citys policies and not for the ones who have posted complaints these issues raise important ethical questions that must be addressed in the new world of ambient intelligence for example with guidelines and best practices that include the point of views of all parties and new coordination theories 57 and mechanisms that manage dependencies among activities until now there has been no reasonably comprehensive survey of ambient intelligence research projects in europe usa and canada focused on privacy security identity and trust issuesstates wright 58 in his safeguards in a world of ambient intelligent project report no one has considered the range of safeguards needed to protect individuals for example in usecase 1 if judys personal data is taken while she is accessing the notes or if the virtual image of kate is usurped for the meeting with judy the negative sides of conviviality by revealing these mechanisms indicate what is to be avoided and point to the mix of different safeguards that have to be put in place to adequately protect individuals groups and institutions from groups to institutions while lomosits 59 recommends that conviviality be achieved through consensus and not imposed hofkirchner 60 identifies the normative idea of unitydiversity as deserving attention when applying conviviality to the level of world society the author examines the unitydiversity relation equates the terms unitydiversity with identitydifference and then describes the four resulting scenarios establish identity by eliminating difference at the cost of the differentiated side yielding reductionism and universalism or of the undifferentiated side yielding unity without diversity that is particularism totalitarianism and homogenization establish difference by eliminating identity yielding diversity without unity that is fragmentation and establish identity in line with difference yielding unity and diversity the achievement of conviviality is in this integration of difference and differentiation of identity yielding for example multiculturalism in usecase 1 censuring particular groups or comments would not be convivial as it would suppress dissident views vital to any community and city but allowing notes from advertisers and malicious users would certainly be nonconvivial for citizens and visitors conviviality strikes the balance conviviality is based on agreements or contradictions states somov 61 he further explains the normative aspect of conviviality with the idea that conviviality belongs to the area of regulation of human interrelations this aspect is why conviviality is particularly relevant to future large scale developments of ambient intelligence summary conviviality a less common view of conviviality that pertains to sociology is when it becomes an instrument to exercise power and enforce one point of view over another 44 conviviality is then experienced as a negative force by the losing side figure 3 summarizes positive and negative aspects of conviviality from different sources the emphasis is on sharing of common grounds and inclusiveness for the positive side and on division and coercive behaviors for the negative side conviviality requirements in this section we discuss conviviality requirements for ambient technology why do we need conviviality few will disagree that conviviality is desirable it has positive effects on society and it is valuable to people in social games such as sl newbies is the name commonly given to newcomers who do not know yet the rules of the game it is rare that newbies escape mistreatment or being taken advantage of by malicious users also called griefers not a convivial relation for newbies recognizing this flaw in their social systems expert players initiated strategies to create more convivial relations with newbies they created services to give newbies special advantages as a kickstart for example free points and advisors to teach them the rules in other words they created convivial conditions for newbies to feel at home integrate the game and in turn contribute to it this generous and trusting attitude established a convivial climate cooperation ruled again similarly with ambient intelligence in usecase 1 gullible new users uploading their notes may give out too much private information giving way to spammers they may inadequately set up their security levels weakening their device barriers and allowing intruders to access their data nevertheless conviviality does not only encourage cooperative and collaborative behaviors it also encourages people to rely on each other get to know their neighbors feel closer and know of each othershabits thereby reducing the need for strong security measures for example in usecase 2 harry plays virtual card games with nick and we assume that these games are convivial as nick trusts harry to meet him in real life and wire him some money from his mobile instantaneously while standing next to him and without fear that he intercepts his personal data in effect local groups autoregulate themselves which at a micro level facilitates decentralization reconciling freedom with exclusion as discussed in section 4 in 1974 ilich defined conviviality as individual freedom realized in personal interdependence the convivial society guaranties freedom for its members to the point of another members freedom as a case in point in usecase 2 harry puts on his privacy jacket to ensure that his walk through a populated area like chinatown will indeed be convivial as a result he still keeps in touch connected he is not isolated as he can still be reached by people he trusts while being shielded from others he may not harry feels safe indeed the vital question is not whether society is convivial but whether the conditions for conviviality can be ensured and for this institutions have a role to play two decades later the semiotician taylor expanded the debate about institutional power and control over social order with her definition of conviviality as an instrument of deception conviviality masks the power relationships and social structure that govern communities for example we assume that in usecase 1 the notes are part of a local community project dedicated to openness and democratic spirit we further assume that the project leaders censure the notes for example by making the unflattering and critical comments unavailable to mobile reach the conviviality users experience while using the system eg posting and reading notes is deceptive the leaders control and manipulate the community through it taylor further asks whether it is possible for convivial institutions to exist this outlook is echoed by ashby when she writes conviviality is achieved for the majority but only through a process by which nonconviviality is reinforced for the minority how to reconcile freedom with exclusion conviviality for ambient intelligence the social navigation system used in usecase 1 illustrates some of the possibilities brought by ambient intelligence it builds on applications such as the massscale annotation system geonotes in this system users annotate physical locations with virtual notes which are then pushed to or accessed by other users when in the vicinity 62 groups of users are hence formed by region in social navigation users further take advantage of social networks with the setup of convivial relations and spaces users are encouraged to share knowledge and cooperate with each other and discouraged to abuse other users now we further imagine that the system allows users to instantaneously exchange their pictures as in 63 when users stand in a particular area for example in front of a historical monument users would benefit from other users pictures but not everyone wants to share or merge their pictures in the context of spontaneous interactions traditional security with the computer journal 2009 authorizations is difficult to apply and innovative approaches based on more dynamic notions such as conviviality have to be investigated the very notion of ubiquitous capture can be frightening the potential capture activity of anyone anywhere may change social relations between people in an overall computing environment focus must be on people and their social situations 64 because conviviality reinforces commonly shared ground between group members protective barriers are created between groups and cohesion is favored within the groups between their members off the groups cooperating objects in the domain of cooperating objects groups of devices spontaneously team up to form brief information systems and perform actions this is illustrated by the concept of spontaneous hot spots for example if in usecase 1 judy notices the posting of a sport event and decides to attend it if during the event many fans judy among then send requests from their telephones to get an instant replay of the last action on the field the video replay resource is simultaneously hit by all the requests the service is satisfying for all with spontaneous hot spots swarms of mobile phones are used to increase the download efficiency of contextrelated resources in a gprs network using bluetoothenabled cooperation 65 as a result users share the network download cost the network load is reduced and the download time is shortened this type of application however raises resourcesharing issues for example available resources should not be overloading the local communication systems and the continuous process of capture should be accompanied by accurate context descriptions giving secure information on quality and origins of the contributions it is more convivial for the audience to access the video replay resource however it should not be at the expense of local citizens outside the stadium who still need to use their mobile devices without added lag times this would not be convivial for them privacy awareness with the increasing number of services and growing capacity of embedded and mobile devices such as pdas and smart phones users rely more heavily on these devices to keep their personal data at the same time people become less aware of the privacy risks they are exposed to for example in usecase 2 harrys car retains much of personal information concerning harry that allows it to drive according to his preferences this information could fall into mischievous hands and sold to advertisers harry could become the target of unwanted sales pitches and spam even worse the preferences may be altered from an itinerary with a preference for tollfree roads to roads with tolls for example current solutions to protect the privacy of users offer them little choice and control over the release of their data an example of privacyaware information brokerage framework is the mobile ubiquitous privacy protection for electronic transactions the system introduces operationfocused access control allows rewarddriven information exchange includes a purpose detection engine and supports explicit as well as implicit purpose activations based on context or authorizations 66 such a system provides ways to differentiate between the goals of the agents that contact users thereby making them aware of the communication and allowing them to decide whether to accept it or not because they increase users choices and possibilities such tools also increase trust and conviviality moreover the capability of tuning privacy policies at the granular level of exchanges increases the likelihood of obtaining a closer match between the resulting policies and the communication exchanges however as the system is based on a constant evaluation of users communications the questions to clarify are regarding the evaluation methods and the inference engine that elaborates the policies moreover errors from the purpose detection engine about the type of context users are in could be very damaging for them and make the systems rather nonconvivial in usecase 2 for example when nick pays harry back with his mobile the device should manage incoming interruptions in a convivial way if a mistake is made on the context eg not recognized as a high security level financial transaction and phone calls are allowed during critical operations consequences can be very damaging privacy and identity theft few will argue that ambient intelligence brings up dark scenarios what lies at the intersection of privacy protection and ubiquitous computing is easy to imagine the frightening vision of an orwellian nightmarecometrue where countless smart devices with detailed sensing and farreaching communication capabilities will observe every single moment of our lives so unobtrusive and invisible that we wont even notice 67 to address the privacy challenges raised by ambient intelligence langheinrich analyzes and proposes a number of guidelines two levels of guidelines are discerned the easiest to implement given the proper protocols are for example to enforce locality by limiting the number of communication hops any message can travel to prevent unwanted surveillance by creating simple proximity behavior for personal devices and to provide some baseline anonymity by devising communication protocols that use temporary random identification for example in the additional usecase examples of collaborative pictures the setting of the boundary that limits where merging of pictures is allowed is crucial guidelines more difficult to implement are for example to find adequate security settings as parts of the system may have different security requirements to create simple mechanisms for pseudonymitybased identity management to fulfill needed trust requirements by implementing digital signatures with corresponding publickey infrastructure and backend systems with privacyaware databases and access technologies the computer journal 2009 convivial ambient technologies 13 to elaborate guidelines for privacyrespecting infrastructures laws and codes of practices together with social and technological realities should be taken into account if certain legal requirements are simply not enforceable technological or procedural solutions need to be found or the law changed states langheinrich we may have accepted that personal data collection everyday erodes our privacy however a number of important threats need to be addressed the improved means of subtly exerting influence and control through the large amounts of personal data that might be collected not covertly but as part of freely chosen services such as loyalty programs recommender systems or payment schemes the increased risk for identity theft and credit fraud through poorly implemented rfid authentication systems hence when developing convivial ambient intelligence tools and systems it is crucial to clearly state the kind and level of privacy needed and to address ethical issues such as identity theft and surveillance summary we draw two main conclusions from our discussion first requirements for ambient intelligence systems expressed by politicians and managers say that systems must be convivial whereas ambient intelligence system researchers and developers use other concepts as an analogy consider in usecase 2 nicks wife who owns and now manages a travel agency she requires her system developers to have a convivial attitude during a meeting in order for example to make it more efficient conviviality during the meeting is used as a tool to achieve the goals of the meeting and when the employees leave the meeting room they go back to their conflicted relations with each other the developers however may not understand the notion of a convivial attitude to model the requirement the developers may interpret the conviviality requirement as being autonomous to make suggestions being reactive to direct the discussion in the meeting to reach their goals being proactive to take the initiative and being goaldirected and most importantly being social by interacting with others to reach their goals second when writing down requirements for userfriendly ambient intelligence systems it is crucial to understand the inherent threads of conviviality whereas conviviality was put forward by illich as a positive concept negative aspects were also discussed people are often not rational and cooperative to achieve conviviality 43 and unity through diversity 60 may lead to suppression of minorities taylor explores the contradiction that conviviality cannot exist outside institutions ie the question whether it is possible for convivial institutions to exist other than by simply creating another set of power relationships and social orders that during the moment of involvement appear to allow free rein to individual expression community members may experience a sense of conviviality that is deceptive and that disappears as soon as the members return to the alienation of their fragmented lives conviviality ontology we are taking up the challenge thrown down by sociocognitive science in order to structure a response in the field of computer science what is the bridge in this section we propose an ontology which straddles the two points of view ilichs personal interdependence and taylors mask for social structure the biting point where interdependence and the mask mesh together is not as mechanically simple as this image may suggest we consider in particular dynamic aspects of conviviality such as the emergence of conviviality from the sharing of properties or behaviors whereby each members perception is that their personal needs are taken care of 42 or ashbys observation that enforcing conviviality for the majority reinforces nonconviviality for a minority 56 after introducing the ontology as a uml class diagram in section 61 we discuss these three elements of our ontology in more detail and explain them by examples in section 62 we discuss dependence networks in section 63 we discuss conviviality masks and in section 64 we discuss normative mas ontology our ontology is visualized as a uml class diagram in fig 4 an ontology is a set of concepts and relations among them which can be extended to a conceptual modeling language on the lefthand side is the usual architecture ontology of software engineering following the ieee 14712000 standard 8 already mentioned in section 21 stakeholders have a viewpoint reflecting their concerns which leads to a view on the system the tropos methodology distinguishes between the early and late requirements of stakeholders which can be expressed in a kind of social network called a dependence network we discuss these software engineering aspects in section 7 when we discuss the design of convivial ambient systems on the righthand side of our ontology we visualize the social concepts the concept of conviviality is not technical and therefore it is a challenge to make it applicable for ambient technology we believe that the ambiguity and vagueness of conviviality is not a valid reason to discard it together with its associated social science literature because this ambiguity and vagueness holds for most other socialcognitive concepts studied in computer systems such as service contract or privacy as discussed in section 2 nevertheless the discussion on the use of social concepts in computer science also highlighted that we have to choose one of the available definitions and which one work best in computer science one option may be to choose a dictionary definition because it has common appeal returning to the definition of the computer journal 2009 section 4 the grand dictionnaire terminologique 47 defines conviviality as follows conviviality is the set of positive relations between the people and the groups that form a society with an emphasis on community life and equality rather than hierarchical functions however we think the dictionary definition would not be a good starting for our ontology the definition of the grand dictionnaire terminologique requires that various other vague concepts are made more precise such as positive relations community life and equality defining one vague concept in terms of other concepts does not bring us much further however the existence of various definitions makes it possible to choose one that fits best the interests of the ambient intelligence community and we therefore use another definition as our starting point our criterion to decide for a definition and ontology for conviviality in computer science is that the vague concept of conviviality is related to other concepts used in computer systems which have got a more technical interpretation surprisingly the most popular promoter of the concept of conviviality has introduced a definition that can be made more precise the concept of conviviality was popularized by a book of illich in 1973 called tools for conviviality in which he defines conviviality as follows conviviality means individual freedom realized in personal interdependence 42 interdependence and dependencies play a prominent role in many formal systems such as for example bayesian networks in this article the notion of dependence is used as it is in mas where dependence relations relate agents who seek to reach their goals to other agents who have the abilities required to fulfill these goals following conventions in game theory as well as mas we say that the ability of an agent to fulfill goals of other agents is an indication of its social power thus our ontology of conviviality in fig 4 starts from the definition of illich by relating conviviality to dependences between agents a dependence network is a social network where the relations among the agents are labeled by a goal expressing that an agent depends on other agents for on the fulfillment of this goal thus dependence networks 1568 model this interdependence among agents highlighted by illich 42 boella et al 12 show how dependence networks can be used to determine which reciprocitybased coalitions can be formed and such reciprocitybased coalitions are an indication of conviviality because reciprocity plays a central role in conviviality conviviality can be measured by the number of reciprocitybased coalitions that can be formed because if this number is high then the agents have a lot of freedom in choosing with whom to cooperate to fulfill their goals as we discuss in section 7 the number of reciprocitybased coalitions that can be formed is also an indication of the conviviality of a design and can therefore be used as a measure to predict whether the system will be convivial moreover we need a mechanism to change the conviviality of a system we define conviviality masks based on taylors idea that conviviality masks the power relationships and social structures that govern societies 44 a conviviality mask is a transformation of social dependencies by hiding power relations and social structures to facilitate social interactions here we interpret power relations simply as a dependence between agents because a dependence reflects that agents have the power to fulfill goals of other agents for the internal dynamics of such transformations we introduce dynamic dependence networks and as a mechanism to enforce conviviality masks we finally introduce concepts from normative mas in our conviviality ontology dependence networks developed by sichman and conte 68 as an extension to dependence network dependence graphs can express the decentralized structures of dependence relationships in mas no agent involved is assigned a privileged role dependence graphs can be used for the study of emerging social structures and for managing the complexity of organizations and institutions these structures are used here to model illichs notion of personal interdependence sichman and conte 68 write that rather than a noneorall notion sic multiagent dependence indicates a phenomenon of growing complexity from loose group dependence to a more structured and more cohesive collective dependence the following definition makes dependence networks more precise a dependence network is a social network in which the relations among the agents are labeled by goals since sometimes only a set of agents can fulfill a goal without the individual agents having the power to do so for example lifting a heavy table of winning the world cup in soccer the dependence relation is not a simple binary relation among agents but a binary relation between agents and sets of agents moreover there can be conflicts between goals such that if a set of agents agents fulfills some goals it may be unable to fulfill other goals we therefore represent the labels by sets o goals that can be fulfilled simultaneously finally we assume that there is a priority order ≥ on the goals definition 61 a dependence network is a tuple a g dep ≥ where • a is a set of agents • g is a set of goals • dep 2 × 2 a → 2 2 g is a function that relates with each pair of an agent and a set of agents all the sets of goals on which the first depends on the second • ≥ a → 2 g × 2 g is for each agent a preorder on sets of goals occurring in his dependencies g 1 ≥ g 2 implies that ∃b c ⊆ a such that a ∈ b and g 1 g 2 ∈ dep definition 62 formalizes that dependence cycles in the graph are potential contracts among the agents and hence potential indications for conviviality we therefore analyze cycles and their configurations in the graphs indeed in convivial places each agent potentially contributes to and receives from any other agents goal and the group however are all contributions really equally convivial from the different types of dependence relationships some rather simple involve two agents that depend on one another for their different goals they are referred to as reciprocal dependence fig 5a illustrates that agent a depends on agent b for goal g 1 and b depends on a for goal g 2 more complex relations involve more than two agents where each may receive help from an agent and may provide help to another they are referred to as amongdependence fig 5b illustrates this relation between agents a b and c in sociology the latter is referred to as a generalized form of exchange potentially requiring complex negotiations even more complex relations involve an agent a that depends on a second agent b for a goal g 1 if it is created by a third agent c giving rise to coalition formation example 1 let dp1 be the dependence network visualized in fig 6 for simplicity we write dep g 1 as dep to express that j depends on r for goal g 1 the figure should be read as follows • agents a j r n judy restaurant and digital notes • goals g g 1 g 2 g 3 g 4 g 5 • the dependencies are dep dep • g 1 ≥ ∅ j prefers to get a nice meal than to have nothing figure 6 illustrates the case for usecase 1 where judy wants to get a nice meal there is only minimal interaction between users however each user fulfill hisher goal no ambient intelligence device is used example 2 building on dp1 new goals listed in fig 7 are activated and new agents added the set n is the set of digital notes left by users let dp2 be the dependence network visualized in fig 8 the figure should read as dp1 with the following additions • the dependencies are dep dep and dep • g 1 ≥ ∅j prefers to get a nice meal than to have nothing the following definition formalizes that the number of ways to form coalitions is an indication of conviviality definition 63 given a dependence network a g dep ≥ conv is the number of distinct potential coalitions which can be defined in dn in dp2 the locationbased information space provides digital notes through mobile networks judy can consult the notes to find and select a restaurant analyzing the graphs we note that the number of cycles in dp2 is greater than in dp1 the number of reciprocity relations among the agents is greater indicating greater conviviality in dp2 than dp1 for the dependence network dp1 the conviviality conv 1 because there are two cycles in the graph one potential coalition between agents j and r for the dependence network dp2 the conviviality conv 5 because there are potentially five cycles in the graph five potential coalitions between agents j r and n a number of other measurements of the cycles in the graph can be taken each potentially indicating the conviviality of the network for example path length structural measurements can be obtained by computing for each node the ratio of incoming edges to outgoing edges for example what happens if one removes the node corresponding to the leader of a group in a centralized group dependence graph 69 in addition we need to analyze the different types of dependencies the dependencies on social norms may have specific mechanisms different from the dependencies on institutions for example in usecase 2 the payment of parking fees is for the state a way to raise taxes reduce pollution and regulate traffic while for the car driver it has different meanings acting with conviviality masks the following definition formalizes that a conviviality mask transforms a dependence network into another dependence network it can both delete dependencies as well as adding new ones by transforming the dependence networks also the conviviality can change in the sense that the conviviality measure may change definition 64 let dn be the set of all dependence networks a conviviality mask cm dn → dn is a transformation function between dependence networks conviviality masks are illustrated in fig 9 given a dependence network the conviviality mask creates a new dependence network visually conviviality masks may be seen as overlays removing some dependencies while introducing others to play a role you need a mask how could judy in usecase 1 order the waiter to bring her a meal if not for the mask they both wear given the circumstance clients are assured that waiters will respond by bringing them a meal as expected similarly clients will act as waiters expect to get a closer look at the relation between mask and role we analyze the scenario of a meeting between colleagues and their supervisor the colleagues have their own personal conflicts with each other however during the meeting all get along fine and the work is done efficiently what happened to their conflicts simply put the colleagues set their expectations differently depending upon if they are in the meeting or not masking the expectations that are not related to the situation during the meeting hence the mask is triggered by dependence relations and uses roles to set patterns of expectations in other words the mask is a tool that filters the appropriate sets of relations for specific sets of situations the mask allows relations to unfold without conflict which is what groups and organizations strive for in order to reach a stable state and last in usecase 1 for example we assume that the system users instead of wearing a convivial mask and leaving courteous notes start leaving hate notes and malicious information users would then not trust the system and rapidly drop it this ties up with taylors definition conviviality masks the power relationships and social structures that govern communitiesthe conviviality mask therefore raises the questions of the use and misuse of conviviality and how to understand it the following definition illustrates how the dependence networks can be modified such that the power of agents to change dependencies among agents is captured in the network itself to model conviviality masks that introduce new goals and therefore create new dependencies among agents we introduce dynamic dependence networks 70 as due to agents actions dependence relations among agents can evolve overtime we extended dependence networks to dynamic dependence networks agents have the power to create new dependencies in the network definition 65 a dynamic dependence network is a tuple a g dyndep ≥ where • a is a set of agents • g is a set of goals • dyndep 2 × 2 a × 2 a → 2 2 g is a function that relates with each triple of sets of agents all the sets of goals on which the first depends on the second if the third creates the dependency • ≥ a → 2 g × 2 g is for each agent a total preorder on goals which occur in his dependencies g 1 ≥ g 2 implies that ∃b c ⊆ a such that a ∈ b and g 1 g 2 ∈ depend the power to change the goals of an agent or to make these goals irrelevant allows an increase or decrease of conviviality in the system for example in usecase 1 we assume that judys friend kate has the physical voucher in her hands and that it is needed to present the actual voucher to redeem the shirt when judy sends an sms to kate to ask her to meet her at the store to choose the shirt with her she now needs to meet her in person so that she brings the voucher judy depends on kate but kate does not depend on judy and may not come not a convivial situation now if on the contrary the voucher can be redeemed electronically or kate wins a gift if she brings the voucher then the dependencies are shifted the former action removes judys dependency on kate while the latter adds a dependency from kate to judy the conviviality mask is put on when judy asks kate to come and help her choose the shirt whereas in fact she needs her to be there for the voucher it is therefore a complete transformation of social dependencies that is performed by the conviviality masks hiding and revealing the power relations and social structures conviviality masks facilitate social interactions in a dynamic dependence network agents have the power to fulfill goals and to create new goal dependencies eg to combine powers to create goals to create new powers and to change priority relations the conviviality mask allows adding and removing goals and powers eg abilities to and from agents in order to adapt the conviviality to specific types of requirements banking transactions for example in usecase 2 when nick pays his debt with his mobile phone require high security and differ from the digital notes exchange requirements from usecase 1 of course conviviality can also decrease dependencies for instance by making goals irrelevant or by assigning new skills to agents so that they are selfsufficient for example if the digital notes were very informative city visitors may not need the tourism office any longer normative mas in this section we relate conviviality masks to normative mas why mas and why normative first in mas an agent is defined as a computer system that is situated in some environment and that is capable of autonomous actions in order to meet its design objectives 71 in short agents can cooperate and coordinate their actions and negotiate with each other most interestingly this autonomy allows agents to take decisions to the computer journal 2009 p caire and l van der torre anticipate social changes and react to it in a group of agents designed to be convivial if an agent a decides to behave aggressively towards others hence violating conviviality rules then the rest of the group must take action against a agent a should be sanctioned boella et al 72 define a normative mas as a system in which agents can decide whether to follow the explicitly represented norms and can modify the norms following the systems specification in the above example the conviviality specification should dictate how and to what extent the agents can modify conviviality relations in this context and what sanctions nonconforming agents should incur this of course raises the question what are convivial requirements adding new technological devices to a system changes the relationships among agents it changes the roles agents hold and the roles that constitute the institution for example in our usecase 1 we assume that judy is at the restaurant a group of students enter with their professor for a lunch meeting one student fred senses judys device and they start communicating with sms and instant messaging we assume that the professor can see the students communications on her own device and block them at will another role is added to the professor eg blocking communication that is not relevant to the meeting which gives her additional power in multiagent perspectives such social roles are instances that can be added to the agents roles obligations and permissions are fundamental features of normative systems they usually include the notion of power and specify their normative and institutional qualities the institutional level of a role describes the agents public beliefs and goals it is highly relevant as it is where different types of powers are associated social institutions are entities that exist not only through the collective consent of public beliefs and goals but also through their regulating rules consequently a role cannot impact an institution without public consent that is the agents social system indeed social and institutional systems as previously seen in section 33 are not physical realities and do not exist without public consent for example institutional views can be defined as follows definition 66 iv rl if rb rg ix beliefs rl → 2 rb goals rl → 2 rg skills rl → 2 x∪ix ir 2 x∪ix × 2 rb → 2 if roles rl → a consists of a set of role instances rl a set of institutional facts if a set of public beliefs attributed to roles rb ⊂ f ∪ if a set of public goals attributed to roles rg ⊂ f ∪ if a set of institutional actions ix a function beliefs that relates with each role the set of its public beliefs a function goals that relates with each role to the set of public goals it is committed to a function skills that describes the institutional actions each role can perform and a set of institutional rules i r that relates sets of institutional actions sets of facts and institutional facts with the sets of institutional facts they see to a function roles assigns a role to its player in a clearly private and public levels have to be separated to avoid possible conflicts between the agents beliefs and the actions they have to perform in order to realize their goals 73 however for an agent to be coherent its private beliefs and goals and its public beliefs and goals although not necessarily the same must be connected for example an agent may have a number of private beliefs and goals as b 1 b 2 b 3 g 1 g 2 and public beliefs and goals as b 1 b 4 g 2 g 3 g 4 in the example above fred may have a private belief that the professor is not competent but his public belief is that the professor is competent as in an educational institution professors are supposed to be competent and students are supposed to recognize it to learn from them therefore a function must relate a private level to an institutional level for beliefs and for goals what then is the difference between the two levels power indeed at the public level an agent can have the power to add to remove from and edit the goals and beliefs of other agents public sets this is not the case at the private level in our example above the professor is not only able to stop fred s messages to judy but also to prevent future messages for example by promising a sanction thereby removing fred s goal to communicate with judy summary an ontology is a set of concepts and relations among them which can be extended to a conceptual modeling language our ontology starts from illich definition of individual freedom realized in personal interdependence and formalized conviviality in dependence networks we measure the conviviality by counting the number of potential coalitions in a dependence network since a larger choice in coalitions represents more freedom for the agents regarding who to work with we define conviviality masks as transformations of social dependencies by hiding power relations and social structures to facilitate social interactions as a mechanism to enforce conviviality masks we finally introduce concepts from normative mas in our conviviality ontology convivial design the conviviality ontology visualized as a uml class diagram in fig 4 illustrates that the bridge between the social ontology and the design of ambient technology is via the dependence networks when early requirements are represented as dependence networks as in the tropos methodology we can very early in the design of the system get a first indication of the conviviality of the system by applying our conviviality measure in other words if the dependence network written down contains many ways for people to interact then it is more likely that the system will be convivial and if there is only one fixed way in which people can interact it is likely that the system will be less convivial of course like any measure that can be applied in early design it is only a very rough measure however in our experience it helps to discuss with the stakeholders during the requirement process to focus attention away from traditional usability concerns toward cooperation among the agents in this section we first give some additional background to this use of dependence networks in early requirements thereafter we discuss other uses of conviviality conviviality measures in tropos in a software engineering life cycle requirements express the customers wishes about what the systemtobe should do in the early requirement phase information is gathered and analyzed while the late requirement phase produces specification documents intended for developers most of existing requirements techniques have been designed for late requirement phases and focus on completeness consistency and verification while early requirements have often remained incomplete inconsistent and ambiguous the early phase however has received increasing attention for being crucial to the success of system development and deployment particularly important questions addressed during early requirement phases of a life cycle include how to address stakeholders interests and concerns why is the system needed what are the alternatives and what are the mutual concessions stakeholders must agree to in order to resolve conflicting situations i proposes to address these questions indepth and at the initial phase of the requirement process with the notion of intentional actor that represent stakeholders intentions and mental states the agentoriented modeling language i which stands for distributed intentionality was developed for modeling and reasoning about actors intentions their organizational environments and their information systems 74 i is particularly appropriate to look inside the actors minds therefore allowing to analyze when and possibly why an actor assesses a group or interaction as convivial or not convivial moreover i represents relationships among actors as sets of dependencies in this sense i is similar to social network methodologies that use relational concepts and analysis of actors interdependencies relational ties patterns and structures these structures can be further analyzed using dependence networks the i framework stands on the representation of two different abstraction levels the intentional level and the rational level the intentional level represented by the strategic dependence model offers a deep understanding of the stakeholders needs in relation with the organization it belongs to sd models describe the dependence relationships among actors in the organizational context the rational level represented by the strategic rational model provides an explicit representation and reasoning about the stakeholders interests and how different configurations of the system address them or impact them sr models building on the sd models provide a more detailed level of modeling by procuring insights on the stakeholders mental states allowing the evaluation of alternative means to reach a goal and help identify other alternatives from the stakeholders point of view in i the sd model is represented by a graph depicting a highlevel analysis of stakeholders social dependencies identified by analyzing users interview reports and domain information actors representing stakeholders and depicted by nodes are endowed with intentional properties eg goals beliefs and abilities the edges of the graph represent the dependence relations among the actors actors depend on each other for a number of reasons to reach goals they can not reach by themselves to obtain a resource needed to fulfill a particular goal and to perform tasks for which they lack the capabilities dependencies represent actors reliance on each other while they seek to achieve their goals hardgoals are distinguished from softgoals the former are concrete goals expressed as functional requirements while the latter difficult to quantify are evaluated qualitatively and expressed as nonfunctional requirements for the system they have no clearcut definition andor criteria for deciding whether they are satisfied or not 75 how to use conviviality measures during design the question we ask for each process is how convivial is this situation hence we look through the conviviality prism from different angles we show how that conviviality is vital for software system design and finally we pin down the means to achieve it the conviviality measure starts from the number of dependencies present in the dependence network that represent the system this measure is low if there are only few dependencies among agents a few coalitions become possible however the number of dependencies is not the only relevant measure but also their distribution must be considered besides counting only the number of potential coalitions we can define also the following measures 70 • whether a dependence can allow an agent to enter a coalition since he has some power which allows him to reciprocate • whether the powers and dependencies are distributed on different sets of agents or not in the first case the risk of a nonconvivial environment increases additionally powers eg abilities can be added to agents in order to create new dependencies for them these changes can turn a nonconvivial dependence network into a convivial one such as in the following examples • if for a given goal an agent is dependent on a set of agents he could be made dependent on different sets of agents in this case his negotiation power for entering a coalition increases 69 • if an agent is dependent on a set of agents he can be given new powers eg abilities and therefore rendered more independent the computer journal 2009 20 p caire and l van der torre • if an agent is dependent on a set of agents powers eg abilities can be added to him to make the agents in the set depend on him • powers eg abilities can be removed from agents who are too independent in order to make them more dependent on other agents • similarly goals can be added to independent agents to make them dependent on other agents in our analysis of these measurements we have to consider real and institutional powers at the same time because both contribute to conviviality 76 let us consider the design for the usecase 1 running example where a tourist judy comes to visit a new city a fourstage design approach is commonly used for the design of digital cities depending on their level of development and can be summarized as follows stage 1 forms brochures and information are put online there is no interaction capability help is provided with a static screen judy can check the city web site for information stage 2 forms can be downloaded but and they have to be sent by mail to the digital city this is oneway interaction help is provided with automatic word completion tool tips and contextual help judy can send a request to the tourism office to get a list of restaurants that give student discounts stage 3 forms can be downloaded filled in on line and uploaded to the digital city this is twoway interaction some adaptive access technologies and ad hoc networking and architectures start to establish seamless interoperability among wireless technologies help is provided with intelligent agents and expert systems through interactive interface while in the city judy has twoway interaction with other users through the digital notes system stage 4 interaction between all stakeholders is performed synchronously and asynchronously in both directions this is full interaction pervasive computing and context awareness deliver enhanced highly usable services to mobile users help is provided with an embodied conversational agent and an adaptive and interactive environment this process is a difficult process due to legacy systems and migration challenges inherent to large systems such as the ones from a city and challenges are to ensure that conviviality is part of the design process judy may be able to interact with personal digital assistants the city would provide over its ad hoc network to visitors evaluations should be performed for each stakeholder group using usecases 1 and 2 running a number of metrics are being reviewed for appropriateness • network analysis to evaluate and compare empirical data for example from a log collected from experiments with a digital city prototype over a few weeks or months to see if the conviviality model actually facilitates conviviality is judy satisfied with the city visit • predictive metrics or design metrics to assess the quality of designs or prototypes for example ease of use for new tourists like judy to find what needed information efficiency and error recovery • preference metrics to quantify the subjective evaluations and preferences of the stakeholders using the system for example the affect of visitors interacting with an intelligent agent for example if harry has a problem with the parking meter and need to connect with an agent the efficiency of the civil servants the helpfulness of the social support forum for visitors the control and ease of learning • user interface design metrics semantic metrics based on content eg how the stakeholders using the system understand the components and their interrelationships procedural metrics that are task sensitive eg how they follow a usecase by performing various tasks and structural metrics based on surface properties such as for example on mobile phones the number of visual components on the screen and the alignment of widgets other uses of conviviality we can extend the ontology to a conceptual modeling language which can be used to define models views and viewpoints on a system an approach on social viewpoints is another way to look through the conviviality prism a persons walk through the process with herhis own view encounters particular situations that can be more or less convivial in usecase 2 for instance harry commands his virtual assistant by voice as to what kind of street he would like to go through and the virtual assistant answers by voice and brings up additional information when available and in accordance with harrys memorized preferences harry can always decide to himself drive the car and change the itinerary the system therefore creates flexible situations for harry he gets more options and greater autonomy to achieve his goals this corresponds to crosiers room for maneuvering and his concept of zone of influence ambient technology gives harry more control on his environment ambient intelligence brings conviviality another reason why conviviality is a useful concept for computer scientists is that the aim of social scientists is not to define the concept but to create conviviality by creating the desired conditions for social interaction this coincides with the aim of designers of ambient intelligence digital cities or virtual communities for example illich defines a convivial learning experience in which the teacher and the student switch roles such that the teacher becomes the student and the student becomes the teacher this role swapping emphasizes reciprocity as a key component for conviviality 77 such role swapping usecases can directly be used in ambient technologies for example in usecase 1 users alternate between leaving and getting notes the ambient intelligence technology here creates the very possibility of role swapping in usecase 1 judy exchanges notes with other system users all users together engage in back and forth communications whereby each contributes and receives from the interactions if most notes were written in a language or protocol judy would not understand she would feel excluded even though for the majority of users understanding it the system would be convivial such a system should therefore be designed to prevent this to happen for example by having automatic translations and help to newcomers finally if people feel more convivial in environments they understand with ease then we must define simplified normative systems and methodologies to develop abstractions that achieve this for example how to develop simplified and transparent systems for new users while preserving all options for expert users how can we define simplified organizations such that new agents meet only a subset of all agents in the system how to define simplified regulations such that new agents can act with more ease what are the abstractions and refinements to make on the dependence networks to achieve these goals the digital divide the gap between technically savvy users and the users is a concern for politicians and administrators the eu simplicity project foresaw that systems beyond 3g and pervasive computing would lead to an increasing number not only of services but also of many different devices and heterogeneous network access technologies however today users who try to use existing services already have to deal with a great numbers and variety of procedures to configure devices of authentication mechanisms passwords requirements payment procedures access technologies and protocols moreover the increasing number of physical devices users should rely upon and carry around has become a challenge even for technical users the digital divide is therefore deepened rather than bridged by new technologies and it has become difficult for users to benefit from new developments the simplicity project was to remedy this situation by simplifying access to services throughout the usecases provided as illustration 78 the emphasis is on the convenience and the apparent facility brought to users however as the system relies on the profile preferences and policy rules defined by the user as well as those selflearned and automatic the threat lies in the users diligence to correctly update hisher profile preferences and rules a process that can prove to be quite nonconvivial moreover the risk of data leakage and a mischievous attack increases with each step indeed in usecase 2 harrys virtual assistant has first to be set up and configured with his preferences a crucial step in the design process of the system and one that imperatively requires convivial attention summary conviviality is a useful highlevel modeling concept for organizations and communities emphasizing social sides rather than legal sides erickson and kellogg 79 say in socially translucent systems we believe it will be easier for users to carry on coherent discussions to observe and imitate others actions to engage in peer pressure to create notice and conform to social conventions we see social translucence as a fundamental requirement for supporting all types of communication and collaboration a digital city should be a meeting place for human and artificial agents in other words the metaphor of the real city should be underlying the design of the digital city in particular using conviviality measures for dependence networks in tropos ensures that conviviality sometimes reduced to userfriendliness is incorporated to ambient systems specifications and design userfriendliness emphasizes unary relations and the notion of use eg the taskoriented aspect of human computer interaction concepts such as affordance ergonomics standards and usability conviviality is primarily concerned with relations between users and areas such as adaptive systems augmented cognition and ambient intelligence there is a widespread belief that user conviviality is something that can be added to a computer system once it has been developed however it is much more difficult to turn a nonconvivial system into a convivial one than developing a convivial system from scratch thus conviviality should be incorporated from the first model of the system related research in this section we discuss related research we start with the research in computer science that has first referred to conviviality then we look at the role of norms as it pertains to conviviality and ambient intelligence finally we look at different kinds of user interactions that relate to the concept of conviviality such as artificial companions and mixed initiative interaction computer science approaches after looking at the multiple and broad range definitions and uses of conviviality in social sciences and noting the number and depth of ethical issues discussed in social science regarding the concept of conviviality we recognize that conviviality raises a challenge for computer science which issues are relevant when developing convivial ambient intelligence how can the positive aspects of conviviality be used for ambient intelligence how should the negative aspects of conviviality be taken into account the role of conviviality in mas in mas an agent is defined as a computer system that is situated in some environment and that is capable of autonomous action in this environment in order to meet its design objectives …agents are capable of flexible p caire and l van der torre behavior 71 this capability is particularly crucial for ambient intelligence since it allows agents to cooperate coordinate their actions and negotiate with each other the use of conviviality for intelligent tutoring systems the system proposed by gomes et al 77 provides a recommendation service of student tutors for computational learning environments each agent pupil represents a pupil logged onto the system one of the functions of the system is to be the client for an instant message service through its agent pupil any pupil can communicate with other pupils in the system another function of the agent pupil is to pass information on the affective states of the pupil this information can be inferred by the agent or be adjusted by the pupil itself the authors claim that convivial social relationships are based on mutual acceptance through interaction hence on reciprocity and in this case students helping each other a utility function takes as input a students social profile and computes the students affective states indicating if the student needs help if she does then the system recommends a tutor remaining challenges are with defining utility function inputs to compute recommendations presently a set of random values and to automate inferences of students requiring help this exposes the urgent need for further research in evaluation methods and measures for concepts such as mood sociability and conviviality the technical challenges of developing convivial tutoring systems are pale in comparison with the ethical issues raised by the possible development of such a system preserving pupils privacy securing the information gathered to create their social profiles deterring possible misuse of pupils affective states and system errors concerning the data in fact it is imperative that designers of such systems use guidelines for instance the european privacy design guidelines for the disappearing computer 80 in order to implement privacy within the core of ubiquitous computing systems 3 noting that these guidelines are not legislative documents we stress the importance of privacy policies to prevent user mistrust that would jeopardize or seriously hinder the development of ambient intelligence the use of conviviality for conversational agent all service offerings must integrate conviviality to the interaction between user and system as an essential preoccupation 43 to fulfill this goal sadek et al define a convivial agent as rational and cooperative an interaction is convivial if the agent presents jointly and at all times one or all of the following characteristics capacity for negotiation contextual interpretation flexibility of the entry language flexibility of interaction production of cooperative reactions and finally of adequate response forms these communicative capacities and social intelligence based on emotional intelligence are crucial to enhance agents ability to interact with users indeed building on this work ochs et al 81 distinguish felt emotions from expressed emotions noting that a person may decide to express an emotion different from the one she actually felt because she has to follow some sociocultural norms we believe this direction to be very relevant to the evaluation of conviviality as it dissociates personal feeling from social expression the use of conviviality for reputation systems reputation is defined as the overall quality or character as seen or judged by people in general and the recognition by other people of some characteristic or ability 82 when casare and sichman 83 state that reputation is an indispensable condition for the social conviviality in human societies they emphasize that reputation provides the transparency quality of the information provided with reputation throughout the group about its member this transparency insures the conviviality of the group as all group members receive the same information about their peers the authors system insures that everyone is aware of anyones behavior that is anyones compliance or not to the rules of the group casare and sichman define a functional ontology of reputation for mas whereby roles are played by entities involved in reputative processes such as reputation evaluation and reputation propagation the authors claim is that concepts of the legal world can be used to model the social world through the extension of the concept of legal rule to social norm and the internalization of social mechanisms in the agents mind so far externalized in legal institutions in their system the agents actual behaviors are compared with the social norms observed in their world the process however presupposes an initial reputation profile of users that agents can then update in real time reputation acts as a communication tool ensuring complete social transparency throughout the system the strict application of norms to reputation however may be difficult and suffer from rigidity of course the same holds for conviviality the role of norms in mas and how it applies to conviviality and ambient intelligence the role of norms is increasingly getting attention specifically in mas where the most common view is that norms are constraints on behavior via social laws 72 in their introduction to normative mas boella et al 72 give the following definition a normative multiagent system is a multiagent system together with normative systems in which agents on the one hand can decide whether to follow the explicitly represented norms and on the other the normative systems specify how and in which extent the agents can modify the normsagents therefore decide how to interact with each other following conviviality conventions or not they can also modify these conventions and thereby contribute to their evolution furthermore the role of norms for conviviality is an instrument for the internal regulation of social systems 84 for example in digital cities government regulations extend laws with specific guidance to corporate and public actions 85 several kinds of norms are usually distinguished in normative systems within the structure of normative mas boella and van der torre 86 distinguish between regulative norms that describe obligations prohibitions and permissions and constitutive norms that regulate the creation of institutional facts as well as the modification of the normative system itself a third kind of norms procedural norms can also be distinguished as procedural norms have long been considered a major component of political systems particularly democratic systems states lawrence 87 who further define procedural norms as rules governing the way in which political decisions are made they are not concerned with the content of any decision except one which alters decisionmaking procedures boella et al further describe action models where agents are goal directed and try to maximize their choice of means to obtain a goal it is assumed that an agent belongs to a group and must follow the norms of the group like all other members in such a system a strategic reason for an agent to chose one means versus another could be based on the gain of conviviality for the group and therefore for himself as well the role of norms for conviviality reinforces social cohesion by reflecting the groups core values internally as well as externally by making the rules explicit the role of norms for conviviality contribute to the elaboration of guidelines for conduct such as privacy protection guidelines crucial for the development of ambient intelligence applications and coordination systems finally the social warranty and protection mechanisms of conviviality are achieved through the expression of its group members feelings toward each other praise and encouragements for members who conform to the rules and anger and blame for the ones who do not such behavior coordination and regulation mechanisms are the very ones that underlie future ambient intelligent society and can therefore greatly gain by explicit conviviality specifications which does not mean that the enduser communication should as well be explicit from explicit to implicit input and output in interactive systems traditionally a human user communicates and interacts explicitly with the system by using a variety of modalities however ambient intelligence creates the need for new forms of human computer interaction transparent and decentralized the concept of implicit human computer interaction proposes to take the users context into account when creating new user interface for ambient intelligence schmidt defines implicit human computer interaction as the interaction of a human with the environment and with artifacts which is aimed to accomplish a goal within this process the system acquires implicit input and may present implicit output to the user 37 the basic idea of implicit input is that the system can perceive the interaction of the user with the physical environment and the overall situations in which the actions take place the system anticipates the users goal to provide appropriate support as illustrated by the following usecase the heatingair condition control system of an office building has access diaries of the people working in the building office rooms are not heatedcooled when people work offsite or are away meeting rooms are heatedcooled in advance of scheduled meetings for more subtle situations for example a light that switches on and off depending on the users action eg reading the newspaper or watching tv the question is how long a situation has to last before the system takes it into consideration issues being raised by ihci are for example how to find and analyze the situations relevant for the system how to abstract from situation to context how to link context to behavior the central questions reside in how to keep users in charge of their interaction and how to achieve a balance between stability and dynamics conviviality can address these questions with for example the notion of dynamic personal interdependence human computer interaction approaches according to lamizet 88 conviviality was elaborated to describe both institutional structures that facilitate social relations and technological processes that are easy to control and pleasurable to use on the one hand conviviality allows individual expression facilitated by personalized interface and customized content while on the other hand it contributes to the standardization of the media and of representation systems in her study of animated toys ackermann 39 looking at the relational qualities of playthings notes that beyond humanoid traits it is an animates manners of interaction that matter beyond smarts it is its conviviality beyond obedience or bossiness it is an animates relative autonomy and ability to share control building on illichs 42 notion of conviviality based on individual freedom and role swapping ackermann explores partial and shared control as critical quality of conviviality toward social intelligence markopoulos et al 89 identify four critical challenges to human computer interaction research for ambient intelligence components designing ambient intelligence systems and environments so that they can be perceived as socially intelligent …designing intelligence that will support humantohuman cooperation and social interactions…how to evaluate social intelligence …what are the benefits of social intelligence the answer to the last question would appear to be a requirement for the evaluation of social intelligence and for designing intelligence that will support social interactions markopoulos et al 89 experimenting with the icat a research platform that exhibits a rich set of humanlike behaviors for studying social robotic userinterfaces further state that for the ambient intelligence research community the challenge ahead is the need to make systems capable of understanding and relating to people at a social level timing and cuing their interactions in a socially adept manner p caire and l van der torre these are some of the challenges that social intelligence design aims to address with methods of establishing the social context embodied conversational agents collaboration design public discourse theoretical aspects of social intelligence design and evaluation of social intelligence 90 as the pervasiveness of ambient intelligence increases so does the need for social intelligence design as a methodology to bring tools like evaluation methods and measures to better understand social concepts such as conviviality artificial companions and mixedinitiative interaction the companions that wilks 91 envisions are persistent software agents attached to single users they act as intermediaries for all information sources that users cannot manage for instance companions for seniors provide company to senior citizens who feel lonely they act as technical task assistant to search the web for travels or keep track of events their owners forget conversely companions for juniors provide assistance with teaching explanationsondemand and advice in a rather new area of research called mixedinitiative interaction people and computers take initiatives to contribute to solving a problem achieving a goal or coming to a joint understanding 92 a critical element is how users focus their attention attentional cues are central in decisions about when to initiate or to make an effective contribution to a conversation or project 93 mixedinitiative research aims at developing software that filters appropriately incoming information to shield users from incoming disturbances such as emails and phone calls the filtering of incoming information is achieved through measuring users keystrokes and scrolling activities recording the number of opened windows analyzing content and checking events in calendars location and time of day and also on psychological insights the psychology of ambient intelligence in 37 a psychological framework for ambient intelligence is proposed based on the concepts of action situation and presence a psychological definition of ambient intelligence based on users experience is given as the effective and transparent support to the activity of the subject through the use of information and communication technologies user activity is defined as the users engagement toward a certain goal while its effectiveness is the degree in which this activity reaches its goal guidelines are provided to support the work of ambient intelligence developers such as an effective ambient intelligent system recognizes users goals the characteristics of the community they belong to and how to support the development of this community it identifies the affordances and constraints of the situation users are in and the tools they need to mediate their activities the notion of presence often described as the sense of being there is defined by riva as an evolved neuropsychological process that controls user activity the feeling of presence provides feedback to users about the status of their activity seeks to remedy breakdowns and to engage in optimal and rewarding activities and experiences this conceptual framework calls for the development of selfadapting interfaces to allow ambient intelligence systems to automatically adapt to a particular end user behavior activity level and social and cultural environment to achieve conviviality for each particular user support to these three kinds of awareness user awareness activity awareness and situation awareness can be extended from individuals to groups and communities to attain convivial ambient intelligence environments conviviality as user experience for ambient intelligence scenarios the goal to design interfaces that are closer to the way human think than the way machine operate raises questions such as what is at this very moment the users state what does she want like need wish is she alone at home in family with friends at work 94 in the context of such spontaneous interactions innovative approaches based on dynamic notions such as conviviality trust and behavior are required furthermore in the area of the disappearing computer the shift from information worlds to experience worlds 95 is particularly significant as stated by de ruyter and aarts 96 user experience for ambient intelligence must be based on safeguarding the privacy of the home environment minimizing the shift of user attention away from the actual content being consumed and creating the feeling of being connected when consuming content over different locations from individual social assistants to communications facilitators numerous research directions in hci exemplify the interest for cognitive and social input to address issues as wide apart as information clutter and digital divide we believe that conviviality can be an important concept to help address the broad challenges of ambient intelligence by providing mechanisms for adaptive user interactions while preserving the granularity of human experience conclusion social concepts like service contract and role are used in a variety of domains of computer science like software engineering business informatics and mas the use of these concepts varies from abstract concepts in requirement analysis via formal concepts in conceptual modeling and measurable concepts in design to programming constructs we argue in this paper that this list should be extended with a sociocognitive concept concerned with agent interaction which is used frequently in the social sciences and has been discussed in applications of mas where artificial and human agents interact like ambient intelligence social intelligence design digital cities and virtual communities this concept is called conviviality in this paper we discuss the use of social concept conviviality for computer science in general and for the development of ambient technologies in particular first we give a survey of the use of the concept conviviality in the social sciences conviviality is usually considered a positive concept related to sociability however further analysis reveals a negative side related to lack of diversity privacy and ethical issues second we argue that conviviality requirements for ambient intelligence are challenging because ambient intelligence artifacts give rise to a new virtual and social reality and conviviality issues play a central role in applications that are concerned with the interaction of material virtual and social realities third we propose a conviviality ontology by operationalizing the fuzzy concept of conviviality such that it can be used in computer science in the same way as other social concepts such as service contract or trust are used in this area conviviality is defined using dependence networks and tools for conviviality are based on what we call conviviality masks fourth we illustrate how convivial ambient intelligence applications can be designed using our operationalized concept of conviviality ambient intelligence applications can greatly benefit from the positive aspects of conviviality sharing knowledge and skills dealing with conflict enabling inclusiveness and encouraging equality and trust among parties however conviviality has first to be expressed explicitly and formalized before it can be used efficiently as a coordination mechanism between individuals groups and institutions and as a tool to reinforce social cohesion there are several reasons to add conviviality as a sociolcognitive concept to ambient intelligence systems models and theories requirements for ambient intelligence systems expressed by politicians and managers say that systems must be convivial whereas system researchers and developers use other concepts when writing down requirements for userfriendly ambient intelligence systems it is crucial to understand the inherent threads of conviviality the use of conviviality as an computer science concept ensures that considerations on the userfriendliness of ambient intelligence systems get the same importance and considerations on the functionality of the system it is a useful highlevel modeling concept for organizations and communities emphasizing the social side of them rather than the legal side fifth the aim of social scientists is not to define the concept but to create conviviality by creating the desired conditions for social interaction we illustrate our arguments and contributions with two main running examples on the use ambient technologies in digital cities as prototypical examples where material reality such as ambient technologies interact with virtual and social realities in the first example a user arriving for the first time in a new city is able to find her way and feel at ease thanks to her mobile phone digital assistant and thanks to the digital notes left by other users in the digital city in the second example a user is driven to the city by his car digital assistant and seamlessly meets his friends in virtual spaces and in real physical spaces we consider the following topics as most important for further research conviviality measures conviviality is important for software systems design involving human actors and to use conviviality effectively we need to measure it therefore we analyzed its effects to allow us to adjust systems to be more adapted to users needs this is particularly relevant in a modern context because of the pervasive development of digital cities dynamic dependence networks the extension of dependence networks with preferences on goals and dynamics normative systems for conviviality masks mechanism for conviviality masks

in this paper we discuss the use of the social concept conviviality for computer science in general and for the development of ambient technologies in particular first we give a survey of the use of the concept conviviality in the social sciences conviviality is usually considered a positive concept related to sociability however further analysis reveals a negative side related to lack of diversity privacy and ethical issues second we argue that conviviality requirements for ambient intelligence are challenging because ambient technologies give rise to a new virtual and social reality and conviviality issues play a central role in applications that are concerned with the interaction of material virtual and social realities conviviality highlights an important challenge that we illustrate with examples that emphasize ethical issues such as privacy threats surveillance of users and identity theft intelligent interfaces for example allow instant interactions and thereby create strong needs for coordination and regulation mechanisms that have to be addressed to ensure the safeguard of individuals against abuses such as privacy intrusions and identity manipulations third we propose a conviviality ontology by operationalizing the fuzzy concept of conviviality such that it can be used in computer science in the same way as other social concepts such as service contract or trust are used in this area conviviality is defined using dependence networks and tools for conviviality are based on what we call conviviality masks fourth we illustrate how convivial ambient intelligence applications can be designed using our operationalized concept of conviviality we illustrate our arguments and contributions with a running example on the use of ambient technologies in digital cities as a prototypical example where material reality such as ambient technologies interacts with virtual and social realities

introduction humans have had a longstanding interest in identifying understanding and cultivating the key ingredients of a flourishing life a multidimensional concept reflecting a state of complete wellbeing in which all aspects of a persons life are good the importance of flourishing is espoused in principles of international agencies dedicated to improving global health notions of flourishing are also interwoven into global initiatives established to promote human development throughout the world for example the united nations 2030 agenda for global transformation includes good health and wellbeing as one of its 17 sustainable development goals similar priorities are reflected in the initiatives of other international entities invested in promoting wellbeing a better understanding of distributions and determinants of wellbeing will provide valuable insight into progress toward many existing global goals and initiatives to this end there are two main limitations in existing empirical research on wellbeing that need to be addressed to support the promotion of wellbeing as a major public health endeavor first most studies focus on a narrowly defined conception of wellbeing this partial assessment of wellbeing is evident in largescale multination reports many of which influence policies strategic agendas and resource allocation decisions at local and international levels for example the world happiness report provides an annual countrylevel comparison of subjective wellbeing this report relies primarily on cantrils ladder a singleitem measure of selfreported life satisfaction life satisfaction is commonly used as a measure of unidimensional wellbeing and has some desirable properties despite the value and potential impact of such analyses such evidence provides an incomplete picture of wellbeing because life satisfaction represents only one of a broader set of indicators for human flourishing a more holistic approach to assessing wellbeing could identify areas of human life that have been overor underemphasized in policies and agendas informing future public health priorities second much of the existing research on wellbeing has overlooked the distribution of wellbeing within populations in favor of assessing trends in population averages an improved understanding of changing inequalities in wellbeing could contribute to policy refinement and more informed resource allocation decisions which may help address social inequities within and across countries in existing research on wellbeing inequalities the focus has usually been on specific aspects of wellbeing to date no study has conducted a systematic global analysis of changing population distributions of wellbeing based on a more comprehensive measure using a dataset with nationally representative sampling consisting of more than one million individuals from 162 countries the purpose of this study is to assess global and regionspecific trajectories of means and inequalities in multidimensional wellbeing from 2009 to 2019 and compare the trends in distributions of wellbeing with more a commonlyused metric materials and methods data data came from the gallup world poll a repeated crosssectional study of nationally representative samples of noninstitutionalized residents aged 15 years or older from 168 countries covering more than 98 percent of the worlds population gwp began in 2005 and collected data from ∼1000 respondents per country annually through 2019 data were collected via facetoface interviews in lowincome countries and via randomdigitdialing telephone interviews in highincome countries with 80 or higher telephone coverage of the population for countries with facetoface interviews the samples were obtained using multistage sampling in which gwp sampled clusters of households as primary sampling units followed by households within the psus and then members in each household this study used data from 2009 to 2019 because some gwp wellbeing items were not measured in prior years we excluded six countries where at least one of the wellbeing measures was completely missing throughout the 11year period the final study sample consisted of 1193134 observations from 162 countries because this study involved secondary analysis of deidentified data its ethical review was exempted measurement using vanderweeles multidimensional conception of flourishing as a framework we assessed five domains of wellbeing that are universally desired and ends in themselves happiness health purpose character and social relationships unlike other theorizing and other existing measures of multidimensional wellbeing this framework suggests that flourishing consists of something more than ones psychological state and thus covers other dimensions of human wellbeing such as character and physical health as well we selected three items that corresponded to each domain among the items available in the gwp specifically we first selected candidate items based on their theoretical fit with the domains of interest and then examined betweenitem correlations to choose three items for each domain only two items had discrete responses ranging from 0 to 10 all other items were binary the full list of items is available in table 1 betweenitem correlations are shown in supplementary table 1 the composite scores for flourishing were calculated as follows first binary items were coded such that positive responses were assigned a value of 1 and negative responses were set to 0 second we rescaled the two items with responses ranging from 0 to 10 to range from 0 to 1 third we took an average of the three items for each domain to obtain domainspecific scores fourth we took an average of the domainspecific scores to obtain a composite index of flourishing lastly we rescaled the composite index by multiplying values by 10 final scores on the composite flourishing index range from 0 to 10 with greater values indicating higher flourishing levels our goal was not to establish flourishing index scores that can be used in future studies but rather to take advantage of the available items in the gwp to roughly quantify multidimensional wellbeing we also compared trends for the index of flourishing to those found for cantrils ladder a widely used singleitem measure of current life satisfaction cantrils ladder asks respondents to evaluate their current life on a ladder scale ranging from 0 to 10 current life satisfaction is one of the three items that formed the happiness domain in our composite flourishing index statistical analysis to assess trends in the distribution of wellbeing we calculated national average and withincountry inequality in flourishing and life satisfaction we measured inequality in wellbeing using the gini index which summarizes the distribution of wellbeing within the population the gini index ranges from 0 to 1 although the gini index is often used to assess income inequality it has also been used in the health disparity literature other measures of health disparity could be used however we decided to use the gini index because it does not depend on the scale and range of the variable being investigated which will facilitate comparisons with future studies we performed the following analyses first we pooled data across years and ranked the 162 participating countries based on mean and gini index of flourishing for the top and bottom 25 countries in both rankings we compared trends in mean and inequality in composite flourishing and cantrils ladder life satisfaction we also compared mean scores for each domain of flourishing across the top and bottom 25 countries second we used the most recent gwp wave to plot and evaluate the relationship between countryspecific mean and inequality in composite flourishing and life satisfaction we also calculated pearsons correlation of mean and inequality for both wellbeing measures third we examined global trajectories of the mean and inequality for cantrils ladder composite flourishing and each domain of flourishing from 2009 to 2019 we calculated countryand yearspecific mean and inequality values for each metric and used their averages as global trends fourth we compared trajectories of mean and inequality in composite flourishing with those in life satisfaction from 2009 to 2019 by geographic regions countries were grouped into 11 regions africa middle east and north africa australianew zealand commonwealth of independent states east asia south asia southeast asia european union europe northern america and latin america and the caribbean figure 1 shows countries included in each category lastly to further investigate differential trends across the wellbeing metrics we pooled the data across years and countries to examine the relationship original responses to 10 were rescaled to range from 0 to 1 between age and life satisfaction composite flourishing and each domain of flourishing we also conducted a series of supplemental analyses first we assessed the relationship between flourishing and life satisfaction by producing a scatter plot of countryspecific mean values for each wellbeing metric and calculated pearsons correlation second to delineate more nuanced patterns we examined trends in mean inequality and age relationship in the wellbeing measures by geographic regions we applied survey weights to all responses to ensure the representativeness of the gwp sample the survey weights were calculated to adjust for oversampling based on geographic regions differential survey modes and household size and to standardize the distributions of demographic characteristics to the 15 population of each country all analyses were performed using r version 360 happiness results country ranking table 2 shows the top and bottom 25 of 162 countries according to mean composite flourishing scores generally countries ranked highly for mean flourishing also tended to have high mean scores on cantrils ladder however there were some differential trends across the wellbeing metrics for example the three countries with the highest mean scores on cantrils ladder were not ranked as highly in terms of flourishing new zealand ireland and australia were the three highestranked countries in terms of flourishing the countries with the highest cantrils ladder values tended to score highest in the happiness domain however they did not perform as well in other domains compared to the countries with the highest flourishing values some countries had an even larger discrepancy between flourishing and cantrils ladder often pertaining to differences in the purpose and character domains moreover countries with similar levels of mean composite flourishing performed differently across the domains of flourishing table 3 shows the top and bottom 25 countries according to inequalities in composite flourishing the inequality ranking was largely comparable with the ranking for mean flourishing as shown in figure 2 countries with higher mean scores tended to have lower inequalities in wellbeing however some countries ranked highly in mean flourishing ranked lower on the gini index temporal trends in wellbeing figure 3 shows the global trajectories of mean scores and gini indexes for composite flourishing and cantrils ladder mean scores for composite flourishing and cantrils ladder were both stable over time regarding inequality of wellbeing the gini indexes for cantrils ladder showed a monotonic increase but remained somewhat more constant for composite flourishing for domains of flourishing we found increasing population average scores and decreasing inequality in the purpose domain in contrast we found decreasing population average scores and increasing inequality in the health domain figure 4 shows regionspecific trajectories of mean scores and gini indexes of composite flourishing and cantrils ladder for both flourishing and cantrils ladder mean scores were relatively stable over time across regions and highest in australianew zealand and northern america the gini index for flourishing was relatively stable and lowest in australianew zealand and northern america however when assessing cantrils ladder there was a monotonic increase in the gini indexes in subsaharan africa middle east and north africa south asia and latin america and the caribbean in other regions the gini indexes for cantrils ladder remained constant or even decreased regionspecific trajectories for each domain of flourishing are presented in supplementary figures 23 overall the temporal trends were relatively similar across regions but differed across domains age and wellbeing figure 5 shows the relationship between age and mean scores for each wellbeing metric we found that the mean for cantrils ladder decreased with age until early adulthood increased with age after early adulthood and declined again in very late life conversely the mean discussion this study investigated global trends in wellbeing from 2009 to 2019 prior work in the field has primarily focused on population averages in wellbeing based on a unidimensional metric such as cantrils ladder as an index of life satisfaction this study adds to the existing evidence by examining multidimensional wellbeing and assessing both population averages and inequalities in wellbeing to do so we leveraged data from the gwp a nationally representative sample of 12 million individuals from 162 countries with a wide range of wellbeing measures our study has three main findings 1 we observed a positive correlation between the mean composite flourishing scores and mean cantrils ladder scores and a negative correlation between mean scores and the degree of inequality assessed by the gini index for both flourishing and cantrils ladder 2 despite the correlation between the two metrics of wellbeing there were distinct patterns in the multidimensional flourishing concerning time geography and age that were not evident when wellbeing was assessed using cantrils ladder as a unidimensional measure of wellbeing despite the correlation between the mean scores and gini indexes we identified nontrivial trends in inequalities of wellbeing that were not detected when analyzing average wellbeing flourishing vs cantrils ladder the comparison of trends in the multidimensional flourishing with those in the cantrils ladder scores gave us at least two major insights first assessing wellbeing using cantrils ladder did not appear to sufficiently capture the multidimensional nature of flourishing the positive correlation between composite flourishing and cantrils ladder suggests value in using cantrils ladder as a simple approach to capture wellbeing trends however there were notable differences between trends in composite flourishing and cantrils ladder for many countries some countries had higher mean levels of cantrils ladder relative to composite flourishing many of those countries scored highly on the happiness domain for which current life satisfaction constituted one item of the index but did not score as highly in other flourishing domains we speculate that this trend may reflect the relatively lower levels of individualism in those countries similarly countries with higher levels of composite flourishing levels relative to cantrils ladder scored lower in the happiness domain but higher in other domains the relationships with age were remarkably different between cantrils ladder and composite flourishing and across the flourishing domains suggesting wellbeing is not a unidimensional construct our finding is consistent with the prior work by huppert and so that analyzed a representative sample of 43000 europeans and examined the relationship between their flourishing measure and life evaluation they found a relatively low correlation between flourishing and life evaluation although their flourishing measure differs from ours in that their measure more extensively covered aspects of psychological wellbeing but omitted some domains that we examined taken together the findings imply that a unidimensional cantrils ladder may adequately assess one dimension of flourishing but fails to identify differential trends in other essential domains of flourishing second even the composite flourishing appeared inadequate and needed to be complemented with independent evaluations of each domain to obtain a full picture of flourishing countries with similar mean composite flourishing levels had different domainspecific wellbeing levels suggesting they require different interventions to promote flourishing further although the global mean level of composite flourishing has remained constant over time wellbeing increased in the purpose domain and decreased in the health domain during the same period collectively these findings suggest that the specific domains of flourishing to be prioritized for the promotion of complete wellbeing did change over time for interventions to be more targeted at the changing needs of wellbeing globally it is therefore important to assess flourishing as a composite as well as with each of the domains previous research focused on cantrils ladder has resulted in insufficient attention to how the interrelationships between purpose character and health shape global wellbeing we found that scores on these three domains decline with age suggesting that interventions might be particularly helpful for older adults in rapidly aging societies accumulating evidence suggests that some of the items we used to measure purpose and character have important effects on population health for example selfreported purpose is associated with lower risk of mortality and increased likelihood of engaging in preventive behaviors similarly volunteering one of our character items has been found to predict lower risk of mortality higher physical activity and a range of wellbeing outcomes including greater purpose more research is warranted to better understand how these three domains impact global wellbeing population average vs inequality although population average scores and gini index were negatively correlated some countries with high population average flourishing had relatively large inequality we also identified rapidly rising inequalities in life satisfaction in africa south asia latin america and the caribbean which might be explained partly by the unequal distributions of life satisfaction drivers in these countries our findings indicate that wellbeing inequalities can arise even when the population average wellbeing appears high or stable over time notably the analysis of average population wellbeing did not provide these insights to inform policies for reducing wellbeing inequalities it is important to identify the drivers of such inequalities and how they differ across populations the wellbeing inequalities observed in this study might reflect increasing social inequalities within some countries while socioeconomic conditions have been documented to affect multiple domains of wellbeing in many studies the relationship might be heterogeneous across populations for instance studies based on european populations demonstrated that socioeconomic factors were associated with mental illness but did not predict mental wellbeing because our measure of inequality summarized overall inequalities within populations future studies are warranted to assess inequalities based on specific social groups while it is informative to study determinants of flourishing that can be altered via interventions targeting individuals future studies should also examine more social and structural determinants of population wellbeing interventions that aim to shift the distribution of flourishing within the whole population may be a more effective public health strategy than intervening among highrisk people at the individual level although the two approaches are not mutually exclusive such populationlevel approaches may also narrow existing inequalities in wellbeing as indicated by the observed negative correlations between population averages and inequalities in this study future directions of wellbeing research our study has three implications for future global research on wellbeing first a multidimensional approach to assessing wellbeing is likely to better inform policies aimed at enhancing human wellbeing more holistically we showed that unidimensional life satisfaction wellbeing assessment a common approach in the literaturemay overlook important trends in other critical flourishing domains because trends can vary substantially across domains of flourishing future efforts dedicated to tracking wellbeing are encouraged to assess composite flourishing as well as domainspecific wellbeing in studying determinants or impacts of policies on population wellbeing assessing domainspecific wellbeing using multiple items is helpful because a specific exposuretreatment can promote wellbeing in one domain and deteriorate wellbeing in other domains for instance evidence suggests that taking care of children as an expression of the self may improve a sense of meaning but can decrease happiness we also need a better understanding of the determinants of the domains of wellbeing for which empirical research is scarce research in this area could provide some explanations about the distinct trends in cantrils ladder and flourishing that we observed in this study one useful approach for such a study is to conduct an outcomewide analysis which examines the effects of a single factor on a wide range of outcomes simultaneously this approach has several methodological advantages and provides a holistic view of the relationships between the exposuretreatment and subsequent wellbeing second more comprehensive measurements for the flourishing domains and inclusion of those items during data collection are warranted most datasets used in public health and social science research do not contain a full set of items to assess flourishing thus a feasible approach has been to use available items as a proxy to characterize the flourishing domain of interest as we did in this study given the theoretical advantage of using multidimensional measures to more comprehensively capture relevant domains of human wellbeing the quality of future research in this area will rest on the development evaluation and refinement of psychometrically sound measures of multidimensional wellbeing that are validated for use within and across different cultural contexts lastly future research should go beyond assessing only average population wellbeing and also pay attention to inequalities of wellbeing within populations tracking population averages may not be particularly informative for a more equitable promotion of wellbeing because as we demonstrated existing and widening inequalities may be masked in such an analysis although we used gini index as a simple measure of total inequality in a population future studies are encouraged to conduct more comprehensive assessment that considers inequality across specific social groups and the scale of inequality measure study limitations three limitations should be noted first our flourishing measures were admittedly crude because of the limited data availability of gwp items some items were as noted above a proxy of the flourishing domain of interest at best for example we assessed the character domain by measuring whether subjects engaged in volunteering donating money and helping others in the past month these arguably do not constitute character itself but rather are its consequences although we may expect these measures to reflect ones character well other facilitators of and barriers to these behaviors may exist such as social norms transportation physical health and financial conditions in assessing the purpose domain we used ones employment status and religious importance but some individuals may not derive purpose from these conditions the items for the purpose domain and the character domain showed weak withindomain correlations furthermore other important theorizing around multidimensional wellbeing exists eg works by although we calculated continuous composite scores for each domain the domainspecific scores were based exclusively on three individual binary items which do not capture the nuanced levels of wellbeing moreover the scores were calculated as simple averages of the individual items thereby assigning equal weight to each item however this studys purpose was not to establish a comprehensive measure of flourishing but rather to use the gwp data as best as possible we did not intend to be prescriptive of what constitutes a good life by choosing the specific items either we aimed to compare trends in wellbeing assessed multidimensionally with those from a unidimensional wellbeing measure hoping to create a foundation that facilitates future research with more rigorous multidimensional wellbeing measures our finding also warrants future studies using other existing data sources that examine wellbeing globally using different items second differences in culture and language may alter peoples perceptions of the world international comparisons involving metrics such as life satisfaction rely on equivalence among translations despite scholars best efforts there are often at least subtle differences between translated terms moreover cultural variation affects how people respond to surveys participants in individualistic contexts tend to emphasize their positive feelings whereas respondents in more collectivist locales may be more likely to downplay these in a selfeffacing manner third the regional grouping we used to categorize countries may be crude other approaches to categorize countries exist although any grouping of countries including ours can be arbitrary and imperfect conclusions in conclusion the current study demonstrated that the standard approach to monitoring wellbeing that assesses population averages using a unidimensional measure might not fully capture complex and changing patterns in wellbeing achieving complete wellbeing is the ultimate goal of many international organizations and global initiatives we propose that future research on wellbeing needs to establish and use more comprehensive multidimensional wellbeing measures and assess population distributions of wellbeing such research would inform a more effective and equitable promotion of human flourishing data availability statement deidentified data that underlie the results reported in this article will be available upon request to and permission by the gallup inc programming code to replicate the study findings will be available upon request to koichiro shiba requests to access these datasets should be directed to supplementary material the supplementary material for this article can be found online at 2022824960full supplementarymaterial conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction human flourishing is a multidimensional concept characterized by a state of complete wellbeing however much of the prior research on wellbeing has principally focused on population averages assessed using a single item of wellbeing this study examined trends in population averages and inequalities for a multidimensional index of wellbeing and compared emergent patterns with those found for cantrils ladder a measure of life satisfaction commonly used as a unidimensional index of wellbeing methods data were from the gallup world poll from the years 2009 to 2019 a repeated crosssectional survey of nationally representative samples comprising ∼12 million individuals from 162 countries we assessed five domains of flourishing 1 happiness 2 health 3 purpose 4 character and 5 social relationships we used the gini index to estimate inequalities in wellbeing within populations we examined and compared country ranking global and regionspecific trajectories of mean and inequality and relationships with age for flourishing and cantrils ladder results although all trends were highly correlated across the two metrics of wellbeing we identified distinct patterns in flourishing concerning geography time and age relationships that were not observed for cantrils ladder temporal trends and age relationships were different across domains of flourishing evidence of changing inequalities in wellbeing was also found even when population averages were high or stable over timecomprehensive measures of wellbeing are needed to capture the complex and changing patterns of wellbeing both within and across populations

introduction china has experienced substantial economic growth in the last decades however this spectacular economic performance is at the expense of the natural environment and ecological resources resulting in heavy consequences 1 achieving carbon peaking and carbon neutrality is an extensive and profound economic and social systemic change they should be incorporated into the overall layout of ecological civilization construction 2 3 4 in the context of carbon neutrality garbage classification is one of the effective ways to alleviate resource and environmental constraints 56 the predicament of urban garbage siege is one of the environmental pollution problems in the majority of chinese cities 7 according to the data from the ministry of ecology and environment of the peoples republic of china 196 large and mediumsized cities generated more than 235 million tons of domestic waste in 2019 considerable quantity of waste is stacked on the land surface without disposing for a long time 8 after suffering a variety of chemical reactions or fermentation the garbage will produce poisonous gas and liquid 9 the emissions of gas will contaminate the air and the liquid will permeate into groundwater together with the rain which causes great damage to the ecological environment 610 the garbage classification addresses the waste disposal predicament facilitate garbage recycling and finally turns garbage into treasure 10 it is noteworthy that the household sector is one of the major waste sources the successful enforcement of garbage classification is closely connected with the wide cooperation and participation of household members 11 essentially garbage classification is a social behavior and entails public participation 1213 researches have pointed out that the unsatisfactory state of garbage classification is led by the low level of household residents participation 1415 theoretically to encourage waste sorting at the source is an effective way to escape the current predicament of waste management 216 in 2019 a mandatory garbage classification policy was first implemented in shanghai since then garbage classification caused a great deal of repercussion in society 17 18 19 by the end of 2020 46 key cities are selected as the first batch of pilot mandatory garbage classification cities these cities basically completed garbage classification and treatment systems the waste is requested to be separated into four categories recyclable hazardous wet and dry waste 20 although policies have been released from the national level a series of incentive and punishment rules are adopted by the local government to promote the residents to participate in the garbage classification 21 such as one of the first pilot city suzhou has issued regulations on the management of household garbage classification in 2022 the garbage classification work has been enforced in 46 trial cities the effect is emerging in major cities such as beijing and shanghai however other pilot cities have space to improve with the processed of garbage classification a series of issues has gradually appeared which can be roughly summarized as facility convenience responsibility of the residents and government work to be specific residents living in community with more supporting facilities are more willing to participate in garbage classification 12 however in some cities such as beijing shanghai guangzhou and shenzhen the garbage classification willingness of the residents is hindered by inappropriate facilities 9 as for the responsibility of the residents their education level sex and age determining the results of garbage classification greatly 22 in addition the government of the cities also issued a serious of measures to promote public garbage classification in shanghai incentive measures including green points policy the distribution of garbage bag and punitive measures such as fine not achieve satisfactory results the reasons for the bad results of garbage classification remain to be explored in existing research most of them apply the method of questionnaire or interview to investigate the residents attitudes and opinions 2324 fewer studies used objective machine learning methods to explore residents emotion towards garbage classification 17 garbage classification comments residents published on the internet contain their perceptions and emotions 2526 their attitudes directly affect the garbage classification behavior thus determining the waste management results 72728 the machine learning method has emerged and widely applied in emotion analysis 29 it can extract vital information in big text data which is suitable for analysing residents attitudes toward garbage classification 3031 thus providing intime feedbacks to governments machine learning methods have been used in the study of proenvironmental behaviors it has been widely accepted as an effective investigative methods 32 33 34 attitudes refer to the assessment individual given to the regulations they are required to perform it is generally separated into positive and negative emotions the positive emotions will promote the residents garbage classification behavior on the contrary negative emotions will deter residents garbage classification behavior it is difficult to accurately investigate residents garbage classification behavior extracting residents emotions from a large amount of text data and using machine learning methods for analysis is an effective way to reflect residents willingness to classify garbage in addition factors affecting garbage classification behavior can be summarized social media represented by sina weibo has billions of users in china 3536 the public can browse realtime news and even ask for help 37 a large amount of data is produced by internet users on social platforms 38 accordingly the test data generated on online social platforms could be used to understand the public garbage classification perception based on text data clawed on sina weibo this paper explores the residents attitudes towards garbage classification and analyse the reasons for residents positive or negative emotions the main contributions of this paper are primarily reflected in the following aspects data on the sina weibo platform was used to analyze publics attitude toward garbage classification measures web crawler technology was applied to collect publics comments on weibo posts related to garbage classification text mining method was used to evaluate publics sentiment toward garbage classification the remainder of this paper is arranged as follows sect 2 is the literature review section 3 delineates the method used in this paper section 4 displays and explicated the results section 5 summarized conclusions and put forward suggestions figure 1 presents the frame diagram of this paper literature review studies on garbage classification behavior like most environmentally responsible activities household garbage classification behavior can be classified into proenvironmental behaviors it requires basic knowledge and skills including identifying waste categories followed by correctly throwing them into the corresponding container for each category 3940 meng et al 41 noted that the lack of garbage classification knowledge is one of the most important reasons caused the residents weak participation li et al 42 argued that garbage classification action is unsuccessfully due to the publics low engagement pothitou et al 24 highlighted that the publics active engagement 1 3 plays a decisive role in the success of waste management furthermore zhang et al 28 point out that inaccurate garbage classification impedes the effects and progress of waste management governments at all levels take all kinds of measures to promote the publics garbage classification participation such as green account points card 43 garbage classification performance among cities demonstrates obvious differences 26 to sum up the publics garbage classification attitude and performance directly determine the success of waste management hence it is urgent to grasp the obstacles people encountered in their garbage classification action in existing literature behavioral science theory is used to analyse the process of the publics garbage classification intention into behavior they all improved with the integration of the additional factors the theory of planned behavior is the most used method to explicate citizens proenvironmental behavior wang et al 26 added personal moral norms and garbage classification knowledge into the tpb to explore the formation process of garbage classification intention and behavior their research found that personal moral norms and garbage classification knowledge are directly and significantly related to residents garbage classification intention norm activation model put forward by schwartz 44 its emphasis on the importance of the cognitive consequences of behavior and positive outcomes will encourage responsible behavior wittenberg et al 45 improved and applied the nam to the investigation of household garbage classification behavior and found problem awareness consequence awareness and subjective norms can significantly predict personal norms in addition behavioral decision theory 46 trust model 47 and learning theory 48 are applied to explain residents garbage classification behavior choice and expression form studies on garbage classification engagement factors it is generally acknowledged that demographic attributes such as gender correlate with individual garbage classification motivations many researches generally assumed that females are more willing to engage the proenvironment behavior 49 education is an important factor has been studied in many researches such as peng et al 50 noted that an individuals education has significant impact on a residents garbage classification behavior and a better education experience will have the promote effects some literatures focus on the residents income they concluded that income has an indirect effect on an individuals garbage classification behavior and higher wealth meaning higher cost 1251 more and more scholars start to pay more attention to social ties 16 52 53 54 zheng et al 55 explored in addition to internal factors external factors also play important role in residents garbage classification behavior zhang et al 56 found infrastructure and government publicity significantly influence the transformation between residents intentions to behavior wang et al 19 noted that any individual has the desire to pursue convenience and simplicity and always hopes to achieve maximum benefits at the least cost they clarify that infrastructure construction is one of the important factors to promote garbage classification trivedi et al 57 delineated the pivotal motivated role media played in the publics attitude towards environmentfriendly packaging previous studies have affirmed the positive effect of the incentive machine on garbage classification 5859 existing literatures also explored the effect of garbage classification knowledge 26 house prices 60 and propaganda 61 sentiment analysis on social media platforms sentiment analysis also known as sentiment orientation analysis or opinion mining is a process to extract information from users opinions 7 it analyzes text audio and images to learn peoples opinions attitudes and emotions 62 the sentimental satisfaction degree of the public with government management is an important issue concerned by academic and political circles 63 it provides a reference for the further implementation of government work at present there are two major schemes to carry the government satisfaction research one is the traditional evaluation model based on a questionnaire survey or interview and the other is the evaluation model based on network public opinion data the research method based on a questionnaire survey is currently the most widely used method in the survey of residents attitude and sentimental tendencies at home and abroad escario et al 15 used the questionnaire survey data of 2487 spanish residents over the age of 17 as the sample to study residents willingness to use the recycle waste based on the databases of the chinese general social survey 20102013 and 2015 zeng et al 61 extracted the issues reflecting environmental attitudes to investigate the publics environmental sentimental tendencies at the present stage song et al 18 randomly selected 265 residents in the baohe and shushan district of hefei to study the residents attitude towards environmental protection payment using the questionnaire with the advent of the big data era more and more scholars started focusing on the largescale user behavior data generated on the network many researchers utilized text mining techniques to analyze some issues such as biomedicine 4664 risk management 3 and public sentiment 65 kolyshkina and rooyen 66 employed text mining technology to assess the impact of text information in claim cost prediction and clarify the new risk management factors renganathan 67 collected a large number of published papers in the medical field and used textmining techniques to obtain valuable information liu and hu 65 collected green buildingrelated hot posts and comments published by sina weibo users through text mining to analyze the publics willingness to pay for green buildings social media platforms are commonly used by people to exchange views and discuss realtime news 35 sina weibo is one of the most influential social media platforms 65 monthly active users of sina weibo have reached 516 million persons more and more people begin to learn about the world through sina weibo therefore sina weibo has become an important medium for people to communicate and express their feelings microblogs published by users are filled with a large number of comments and opinions with sentimental color which makes these microblogs have important economic and social values in both business analysis and public opinion monitoring 7 therefore it is an appropriate platform to study the chinese publics attention towards garbage classification in summary although previous studies 171928 have discussed residents attitude towards garbage classification from the data of questionnaire surveys or interviews the analysis data used is subjective moreover the method of questionnaire survey is subject to time and space constraints in the process of implementation which requires a lot of data input and statistical work its evaluation system is difficult to measure the dynamic changes in peoples feelings towards government departments to fill these gaps this paper uses a web crawler combined with text mining technology to analyze the public online discussion on garbage classification strategy so as to understand residents attitudes more objectively based on the micro blog text data mining we use the linear discriminant analysis topic model to compare the topic proportion of micro blog text and use the sentiment dictionary method to get the positive sentiment tendency score and negative sentiment tendency score methodology web crawler technology with the popularity and prevail of the internet online information resources have experienced explosive growth to dig out valuable information from enormous network resources web crawler technology has appeared web crawler technology is a method that automatically accessing required information from one or more web pages according to a certain strategy and is a path to acquire online resources through a simulated browser web crawlers are generally divided into four types based on the diversities in target objects system structures and fulfilment techniques the names of these four types are the generally service web crawler the target web crawler the incremental web crawler and the deep web crawler respectively in this paper we mainly used the target web crawler technology to collect the information needed python is a mature generalpurpose programming tool we used python39 to clawer the microblog text data in addition visual studio code is a mature application software used widely on web crawler technology thus we collected the required text information based on visual studio code the steps for accessing text information on sina weibo were as follows simulated login using the username and password of a sina weibo account we implement simulated login in sina weibo through google web page downloading and data filtering after the simulated login the initial link that defined the information collection was weibo cn based on the concept of garbage classification and the research target of this paper garbage classification was set as predefined keywords to collect information on weibo users and weibo posts key content collection when collecting the personal information of weibo users we collected the username content of the post number of collections number of reposts number of comments number of likes and post time information storage and export after all information and texts were collected a repetition test was conducted until all the years data finished and then all the contents were exported we protect the personal privacy of internet users and adhere to strict confidentiality by withholding individual information it also guarantees that this information will never be disclosed to any organization or individual text mining technology texting mining refers to extracting valuable information and knowledge from big text files using computer processing technology through text mining the residents attention status and changing trends toward garbage classification can be accessed and analyzed text sentiment analysis also called opinion mining refers to a series of processes such as analyzing processing inducing and reasoning aimed at the subjective text with sentiments based on the sina weibo text collected we chose the sentiment dictionary method to analyze the sentiment of public garbage classification as the bosonnlp sentiment dictionary was constructed based on the microblog news forum and other data sources we conducted the research with this dictionary instead of media weibo the text data used in this paper only contains weibo published by personal accounts to ensure that all texts reflect the opinions and opinions of residents thus it can be concluded that the chinese publics sentimental orientation and attention to garbage classification the steps were as follows denoising we have deleted text data with the disordered format and missing content there are also some repetitive and meaningless information in the microblog such as advertisements retweets information with too few words and information without practical significance in addition the content of weibo that is not related to the topic of garbage classification will be further cleaned up therefore the arrangement of the text data is basically completed and the next step is to analyze the text content application of the bosonnlp sentiment dictionary the sentiment dictionary contains a word segmentation dictionary and a word sentiment weight dictionary the word segmentation dictionary is employed to segment sentences of text into individual words and emoticons while the sentiment word segmentation and assigns sentiment values according to the sentiment strength of words and emoticons bosonnlp sentiment dictionary is a sentimental polarity dictionary automatically constructed from millions of sentiment annotation data from data sources such as weibo news and forums since the annotations include weibo data the dictionary includes many internet terms and informal abbreviations and it also has high coverage of nonstandard texts the sentiment dictionary is very suitable for building social media sentiment analysis engines negative content discovery etc sentiment analysis word segmentation after segmenting the weibo sentences with the word segmentation dictionary the words and phrase in the sentences were recognized calculation of sentiment score based on the sentiment weight of words and sentiments the modifying relation between different parts of the sentence the mood of the sentence and so on the sentiment value of the sentence was calculated based on the given word sentiment weight dictionary in the bosonnlp sentiment weight dictionary each line is a sentiment word and its corresponding sentiment score separated by spaces including 114767 chinese words in total among them negative numbers represent negative words and nonnegative numbers represent positive words the degree of positive or negative can be reflected by the magnitude of the value the classification of the sentiment in this paper sentiment orientations are classified into positive sentiment and negative sentiment based on the positive and negative sentiment value of comment sentences besides according to different sentiment degrees positive sentiments are further classified into two categories of sentimentsgoodness and pleasure in the meanwhile negative sentiments are classified into five categories of sentiments with successively increasing sentiment degree shock disgust fear depression and anger topic focus analysis through the word frequency analysis of the text the focus of the publics attention is obtained and the reasons for the publics sentiment tendency are analyzed accordingly results and analysis in this paper we obtained the text data with the predefined term chinese word garbage classification on sina weibo from 2015 to 2020 to dig out the problems related to garbage classification that are of great concern to the residents a total of 9433330 posts are collected through the analysis results of text mining we can grasp the residents attitude towards garbage classification and understand what motivates or hinder the residents garbage classification action all these results will give a reference to the government on how to promote garbage classification work public attention status toward garbage classification sina weibo users have two categories institutional and individual users considering that the microblog of institutional users cannot reflect residents attitude we only use the individual authenticated users microblog in sentiment analysis public attention at the national level due to the domestic sina weibo users account for 935 the microblogs can reflect the current situation in china in terms of the number of microblogs the sum of the number of collections reposts comments and likes of a microblog post was defined as the amount of attention the post received as shown in fig 2 it presents an increasing trend it is noteworthy that visible rise occurred in 2019 it may be due to the implementation of a mandatory garbage classification policy regional analysis registration for a sina weibo account only needs a cellphone number most of the sina weibo users have not completed their basic profiles information in our data collected more than half do not fill in their location information as the serious data loss of users profiles the gender and regional difference have little value therefore this paper will not display the gender difference in the word frequency analysis section some cities received outstanding attention we analysis the regional heterogeneity from the word frequency perspective in 2015 guangzhou shenzhen and hangzhou list in the top 100 keywords the three cities shenzhen issued measures for the administration of household garbage classification fig 2 the number of microblogs with the predefined search terms garbage classification and reduction and hangzhou started to fully implement garbage classification in 2019 shanghai attracted the most attention word frequency is 20832 shanghai becomes the first mandatory garbage classification city and arouse enormous reaction xian also received plenty of concern rank the second in 2020 garbage classification in beijing and shanghai is discussed most it is related to beijing carry out a garbage classification policy formally in 2020 sentiment orientation analysis based on the data collected from sina weibos comments and sentiment orientation analysis adopting the nlpirparser platform results show that positive sentiment accounted for 546 558 575 603 60 and 597 from 2015 to 2020 respectively it indicates that there is half of the residents have a positive attitude towards garbage classification however residents proportion have negative attitude is nearly the same as positive emotions as shown in fig 3 the positive score and proportion are increasing from 2015 to 2020 while the negative tends to decrease it reflects the residents garbage classification recognition rising and the government work achievements emerging preliminary from the perspective of the citizens propaganda of garbage classification policies and the improvement of national cultural quality will promote their recognition however the recognition level is not high on the whole it remains to be further pushed in the initial stage of garbage classification due to the longterm thinking habit and lifestyle they are hard to adapt to the new regulation word frequency analysis in this section the top 100 chinese words with the highest frequency are summarized from the mining of microblog texts from 2015 to 2020 and the result displayed has all been translated into english through the analysis of keywords the hot 100 topic people are concerned about can be grasped thereby to adjust the policy in time as for the limited length we display the top 10 keywords for analysis from fig 4a it can be seen that the topic people discussed most in 2015 is the garbage classification activities carried out by communities and work units the major motivation for the public to carry out garbage classification is the psychological fulfillment to participate in proenvironmental behavior it is owing to the increasing environmental awareness the harm of environment pollution gradually emerged the public has become increasingly focused on human beings and nature especially the improved education level which is directly related to the increasing awareness of environmental protection among the public garbage recycling is also an important topic of garbage classification that the public is concerned about in summary it can be seen that the publicity work of garbage classification has been carried out has increased the publics awareness to classify garbage to a certain extent from the results that not displayed 20th to 100th keywords we can conclude the public showed great enthusiasm for the knowledge learning of garbage classification which is related to the enforcement of mandatory garbage classification measures the change of garbage cans also receives lots of attention which is due to the trash bin has become more diverse in addition the disposal of kitchen garbage is a hot topic as kitchen garbage occupies a major position in domestic garbage mainly leftover meals and soup etc it has a strong smell and is more troublesome to collect and dispose of at present the most urgent garbage classification work in china is to separate wet garbage from kitchen garbage the classification of food waste still largely depends on the consciousness of residents garbage classification education has been embodied in childrens daily learning and volunteers are an important force to promote garbage classification volunteers distribute garbage classificationrelated leaflets manual in the community they set good examples which have greatly increased the enthusiasm of residents to participate in civilized activities and also increased peoples support for garbage classification regulations as for the garbage category the classification of glass is a key issue of public concern after the outbreak of covid19 in 2020 the classification of masks has become an important topic again the publics hope for a green environmentally friendly beautiful and civilized society is an important internal factor that drives the public to carry out garbage classification which is related to the governments publicity of garbage classification knowledge sentiment foci negative sentiment foci as for the limited space we only display the lda results of the nearest year 2020 table 1 shows the feature words of the weibo text data of garbage classification negative orientation in 2020 from the results both displayed and nondisplayed we can summarized the main reasons for the negative sentimental orientation of garbage classification are the mandatory implementation of the garbage sorting policy is too sudden to accommodate among the punishment rules fine is the residents most resistant measures garbage classification infrastructure is not perfect such as the location of trash cans in addition the dispense of biodegradable trash bags suffers from irregularity at the beginning of the implementation of the policy all departments worked very enthusiastically however garbage sorting lost its enthusiasm after a long time it shows that the garbage classification work is superficial at present not as a longterm work some people even think that garbage classification work is a form the promotion of garbage classification has not formed a scientific orderly unified system structure as mentioned in the text my garbage is classified the community is not classified the city is not classified the society is not classified… ive classified it and its not worth it if the work of a certain link is not in place the garbage classification work is not completed figure 5 displays the feature words in a visual form as an example we can identify the public sentimental focus by the keywords on the right side of the picture the blue bar chart on the right side of the picture indicates the total frequency of occurrence of a certain keyword in the text the red bar chart shows the total frequency of a keyword in the selected topic the circle on the left of the figure represents the topic of the text and the distance between the circles represents the distance between the topics due to a large number of themes each theme will not be displayed one by one in this paper this article selects the first theme in 2020 as an example for analysis positive sentiment foci table 2 shows the feature words of the weibo text data of garbage classification positive orientation in 2020 from the results both displayed and nondisplayed we can summarized the main reasons for the positive sentimental orientation of garbage classification are the publics own environmental responsibility with the deepening and popularization of environmental protection propaganda in the whole society public awareness of environmental protection is enhanced more and more people are willing to participate in garbage classification to achieve the goal of sustainable development some effective incentives the most obvious of which is the redemption of green account points have promoted the publics willingness to garbage classification the volunteer successfully achieve the demonstration effect and enhanced the publics willingness to classify garbage besides entertainment stars also call on a multitude of their fans to devote to garbage classification figure 6 displays the feature words in a visual form as an example conclusions and policy implication residents are direct participants in garbage classification and increasing their willingness to classify can improve the effect of garbage classification to grasp the publics sentimental orientation provide a basis for government work it is crucial to effectively adjust rules to grasp the reasons that promote and hinder residents garbage classification in time based on the garbage classification comment text data released by residents on the weibo platform from 2015 to 2020 this paper analyzes the most concerned issues of the public in the garbage classification process the main conclusions can be summarized as although garbage classification has been promoted with great efforts in recent years the proportion of residents holding negative sentiment towards garbage classification as high as 55 the publics positive sentiments are mainly caused by the publics responsibility and the incentive measures adopted by the government the main reasons for negative sentiments are imperfect infrastructure and unreasonable garbage sorting arrangements the obstacles to the classification of residents garbage are mainly the unsustainable measures taken by the government for example the distribution of degradable garbage bags is irregular garbage classification work floating in slogan at present lack of long time momentum among the garbage classification work kitchen garbage classification encountered the most shows a great discrepancy the governments of the pilot cities beijing shanghai guangzhou and hangzhou have adopted the most garbage classification measures and has the greatest responses the different garbage classification policies in various places are also an important reason for residents disgust based on the research results this paper puts forward the following suggestions according to the results opposition to incentive or punishment measures is an important source of public negative emotions about garbage classification to win public support for the incentive or punishment measures fundamental understanding of the residents response to the incentive or punishment measures is essential for example before adopting the incentive or punishment measures use the questionnaire survey to investigate the residents habits and thinking characteristics to enhance the wide public support for the policy attaches great importance to the cultural psychological and cognitive factors of individual actors at the micro and macro level of social action system of consideration the system of urban environmental protection policy should not only pay attention to the policy enforcement but also attaches great importance to the process of informal institution building such as taking garbage classification into school education and continue to carry out publicity activities based on the result that the public is not satisfied with the infrastructure construction the garbage collection devices need wellplanned such as properly plan the location of garbage cans time to collect garbage only by making the garbage classification process convenient and userfriendly can the residents will more willing to participate in the garbage classification work there are still research limitations to our research as the users of sina weibo are generally young so the data used in this paper is less effective for the investigation of the garbage willingness of the older of jiangsu province the national natural science foundation of china and the carbon neutrality and energy strategy think tank project of china university of mining and technology we also would like to thank the anonymous referees for their helpful suggestions and corrections on the earlier draft of our paper upon which we have improved the content

china has been implementing garbage classification to improve resource recycling for many years since garbage classification is essentially a social activity it needs the active participation of the public however the phenomenon of high practice low effect is widespread in most cities therefore this paper uses the data from sina weibo to analyze the reasons for the poor garbage classification effect first the key factors affecting residents willingness to participate in garbage classification are identified based on the textmining method further this paper analyzes the reasons that promote or hinder the residents intention of garbage classification finally the residents attitude towards garbage classification is explored by the score of the texts emotional orientation and further the reasons for the positive and negative emotional orientation are analyzed respectively the main conclusions are as follows 1 the proportion of residents holding negative sentiment towards garbage classification is as high as 55 2 residents positive emotions are mainly caused by the publics sense of environmental protection inspired by publicity and education and the incentive measures taken by the government 3 the main reasons for negative emotions are imperfect infrastructure and unreasonable garbage sorting arrangements

introduction social governance is a process in which the government and all walks of life work together to solve social problems maintain social order and promote social harmony and stability through rules policies resource allocation and service provision social governance aims to realize public interests and meet the various needs of social members covering the participation of the government social organizations enterprises and residents grassroots government usually refers to the lowest level of local government including counties townships and villages and its main responsibility is to manage and serve local communities 1 grassroots government plays an important role in social governance which is responsible for solving social problems in the region providing basic public services and maintaining community order 2 the role in social governance refers to the different roles and functions played by the government social organizations and citizens in the process of governance the government plays the role of formulating policies regulations providing public services supervision and coordination and social organizations are usually nonprofit organizations which bear the role of supervision service publicity and participation 3 as a part of society citizens have the right and obligation to participate in social governance and put forward opinions and suggestions social governance strategy is a longterm planning and action plan adopted by the government to deal with social problems and promote social progress these strategies include measures such as policy formulation resource allocation public service provision social innovation and reform 4 the formulation of social governance strategies needs to consider the complexity and diversity of society in order to effectively cope with the challenges in different fields social governance practice refers to the process that the government and all walks of life solve social problems and promote social progress through specific actions and project implementation according to social governance strategies which includes specific measures of grassroots governments such as project implementation service provision community management and crisis response 5 social governance practice usually needs to consider factors such as resource allocation cooperation and coordination community participation data analysis and effect evaluation social challenges and problems refer to various unfavorable factors and difficulties faced by society such as poverty unemployment crime environmental pollution social inequality and so on 6 these problems affect the stability and development of society and need the joint efforts of the government and all walks of life to solve them the effectiveness of social governance refers to the results and effects achieved by the government and other social organizations in the process of social governance it can measure whether the implementation of the policy has achieved the expected social goals including solving problems improving service quality improving living conditions and promoting social harmony 7 social harmony and stability is one of the important goals of social governance which refers to the harmonious relationship between various groups in society and the stable state of social order the maintenance of social harmony and stability is conducive to the sustainable development of society and the realization of public interests 8 analysis of the role of grassroots government in social governance in social governance grassroots governments as the bottom units of the government system play a crucial role this section will explore the different functions and roles of grassroots governments in social governance through detailed role analysis including policy formulation and implementation social service provision community construction and management social mediation and conflict resolution as well as information transmission and promotion in order to comprehensively understand their key role in social governance policy formulation and implementation one of the primary responsibilities of grassroots governments in social governance is to participate in policy formulation this includes processes such as government planning project management and regulatory development grassroots governments must ensure the feasibility and adaptability of policies at the local level to meet the specific needs of communities this process involves policy analysis drafting of legislation and public participation 9 once policy formulation is completed grassroots governments have a responsibility to ensure the effective implementation of policies this includes tasks such as resource allocation supervision and improvement of execution policy implementation also requires cooperation between grassroots governments other government departments social organizations and enterprises to ensure the comprehensive implementation of policies social service provision grassroots governments need to develop social service plans determine the scope goals and resource allocation of social services this includes service planning in areas such as education health and social welfare to meet the basic needs of community residents grassroots governments are one of the main providers of social services undertaking responsibilities such as education healthcare and social welfare this includes the operation and management of facilities such as schools hospitals and social welfare institutions to ensure that residents can access highquality services community construction and management community construction and management are one of the core responsibilities of grassroots governments in social governance aimed at maintaining the orderly development of communities improving the quality of life of community residents and promoting community harmony and stability community construction refers to the comprehensive development and improvement of communities promoted by grassroots governments through planning investment and resource allocation 10 grassroots governments need to formulate urban and land use plans to ensure the rational development and utilization of land resources within the community this includes the planning of residential areas commercial areas public facilities green spaces etc to meet the different needs of the community communities need to have good infrastructure such as roads bridges water supply systems sewage treatment facilities electricity supply etc to provide convenient living conditions grassroots governments should provide social service facilities such as education healthcare culture sports and social welfare to meet the needs of community residents community management is a key link in ensuring the orderly operation of the community and a series of management measures need to be taken as shown in figure 1 figure 1 management measures community leaders should develop and implement community rules and regulations clarifying the rights and obligations of community residents this includes regulations on residential rules public order maintenance environmental protection etc to ensure the harmony and order of the community grassroots governments need to ensure the safety of communities including crime prevention fire safety traffic safety and other aspects local authorities should establish patrol teams security facilities emergency rescue systems etc to improve the level of community safety they should also coordinate social service resources to ensure that community residents have convenient access to services such as education healthcare employment and social welfare additionally social service centers consulting institutions etc should be established to provide assistance and support residents should be encouraged to participate in community management and autonomy community management and community committees resident councils and other institutions to enable residents to participate in decisionmaking and management of affairs furthermore there should be timely transmission of government policies and community information to enhance residents understanding of community affairs this includes using social media official websites traditional media and other channels for information promotion local authorities should establish an emergency response mechanism to respond to natural disasters emergencies and other emergency situations and protect the life and property safety of community residents strategies and practices of grassroots governments in social governance social governance strategies of grassroots governments the social governance strategies of grassroots governments play an important role in maintaining social order promoting community development and improving the quality of life of residents these strategies aim to address various social challenges and problems and provide effective governance measures this article analyzes the social governance strategies of grassroots governments and describes them from four aspects as shown in figure 2 multi level governance model the multilevel governance model emphasizes the coordination and cooperation among various levels of entities such as government departments social organizations enterprises and residents to solve social problems the core idea of this strategy is to delegate governance power to lower levels enabling grassroots governments to respond more flexibly to local issues while ensuring guidance and supervision from the central government in a multilevel governance model grassroots governments need to establish partnerships and work closely with other government departments nongovernmental organizations enterprises and community residents to jointly formulate and implement social policies this cooperation can be achieved through mechanisms such as joint working groups cooperation agreements and cross departmental committees for example when dealing with environmental issues grassroots governments can collaborate with environmental organizations enterprises and local communities to jointly develop environmental protection plans and measures public participation mechanism the public participation mechanism is a strategy adopted to ensure that government decisionmaking is more democratic transparent and participatory grassroots governments should actively listen to and absorb the opinions and suggestions of residents in order to better meet their needs and improve the quality and legitimacy of decisionmaking grassroots governments can organize citizen consultation meetings and hearings inviting residents and stakeholders to provide opinions and suggestions on policies and projects conducting community questionnaire surveys can help understand the needs and concerns of residents to guide government decisionmaking establishing community representative organizations or resident councils provides residents with the opportunity to participate in decisionmaking and supervise government work we need to utilize the internet and social media platforms to enables residents to participate in policy discussions and provide feedback online transformation of government functions the strategy of transforming government functions aims to transform grassroots governments from traditional managerial roles to serviceoriented roles focusing on providing public services creating public value and promoting community development grassroots governments should provide highquality public services including services in areas such as education healthcare social welfare culture and sports the government should ensure the accessibility and fairness of services to meet the needs of different residents encourage and support innovation and entrepreneurial activities to promote socioeconomic development the government can provide support measures such as entrepreneurship training venture capital funds and technology parks grassroots governments need to formulate community development plans clarify development goals and directions and ensure the sustainable development of communities the government should be committed to promoting social fairness and justice reducing the wealth gap providing equal opportunities and ensuring that every resident can enjoy basic rights and wellbeing the application of innovative technologies in modern social governance the application of innovative technologies has become crucial grassroots governments can use tools such as information technology big data analysis and artificial intelligence to improve governance efficiency and service quality the government should establish an egovernment platform to provide online government services simplify administrative processes and improve administrative efficiency utilizing big data analysis to understand community issues and needs helps in developing more precise policies and services adopting smart city technology is essential to improve the urban management level optimize resource allocation and enhance the urban environment and transportation interacting with residents through social media platforms transmitting government information listening to their voices and enhancing government credibility are crucial components of effective governance social governance practices of grassroots governments the social governance practices of grassroots governments cover a wide range of fields aiming to maintain social stability improve the living standards of residents and promote community development the social governance practices of grassroots governments can be divided into four aspects as shown in figure 3 these social governance practices reflect the key role and responsibility of grassroots governments in social governance the government needs to continuously improve and innovate social governance methods to adapt to the changes and needs of society at the same time grassroots governments also need to establish effective partnerships and work closely with social organizations enterprises and community residents to jointly achieve the goals of social governance conclusions grassroots governments play multiple key roles in social governance and their social governance strategies and practices have a profound impact on social stability development and the quality of life of residents the adoption of a multilevel governance model helps to coordinate various forces such as government departments social organizations and enterprises at all levels to address complex social issues the public participation mechanism emphasizes the democracy and transparency of decisionmaking enhancing the legitimacy of decisionmaking in terms of social governance practice community construction and planning are the primary tasks of grassroots governments covering areas such as urban planning infrastructure construction and environmental protection the provision of education culture and social services helps to improve the quality of life of residents and the development of communities community safety and crisis management ensure the safety and stability of the community in practice grassroots governments need to fully recognize the importance of their social governance role continuously improve their management and leadership capabilities strengthen cooperation with community residents and stakeholders and respond to social challenges and problems the government needs to flexibly respond to the constantly changing social environment adopt innovative and technology driven methods to improve governance efficiency ensure social stability and improve the quality of life of residents this will contribute to the continuous improvement and development of the social governance system providing a solid foundation for sustainable progress in society

in the study of the role and strategies of grassroots governments in social governance this article clarifies the core theme and explores the role and strategies adopted by grassroots governments in social governance in terms of role analysis the article discusses in detail the multiple roles of grassroots governments in social governance including policy makers public service providers regulators coordinators and community participants the complexity and interactivity of these roles highlight the multidimensional role of grassroots governments in social governance in the strategy and practice section this article mentions a series of social governance strategies adopted by grassroots governments such as multilevel governance models public participation mechanisms government function transformation and the application of innovative technologies the purpose of these strategies is to improve governance efficiency promote social fairness and justice ensure social security and sustainable development while encouraging active participation and autonomy among community residents

introduction as the conflict in syria continues the death toll and displacement of people in the country also continue to rise currently more than 56 million refugees are registered with the united nations refugee agency and living in neighbouring countries in the middle east and north africa 1 2 3 4 further more than 6 million people are displaced internally in syria and another 135 million people in conflictaffected areas in syria are in need of humanitarian aid 45 as of may 2018 54560 syrian refugees had been admitted into canada and three of four refugees are women and children 67 refugees to canada may be admitted through the governmentassisted refugee program the privately sponsored refugee program or the blended visa officereferred program gar and bvor refugees are referred by the unhcr or other referral agencies for settlement in canada while psrs are named by the respective sponsors who are groups of canadian citizens or coalitions 68 although all refugee applications are screened and processed by canadian visa officers the referral process and the financial support provided to refugees once in canada differ across three programs upon arrival to canada all refugees are provided with financial support for 12 months the support is given by the federal government in the gar program private sponsors in the psr program and both parties in the bvor program in 2015 most syrian refugees were admitted through the gar program with the federal governments plan to increase the number of refugees accepted through the psr program the percentage of refugees admitted through the three programs changed in 2018 to 49 by the gar program 42 by the psr program and 9 by the bvor program 6 almost half of all syrian refugees to canada have settled in the province of ontario and about 45 of them are now living in toronto 46 refugees admitted through the gar program are reported to be the most vulnerable and atrisk for physical and psychological health problems 9 all refugee claimants undergo a medical examination before they are accepted although applicants are not rejected because of their medical burden they could be delayed if they have an infectious disease the international organization for migration handles the arrangements for the trip to canada paid for by the refugee if they cannot afford the money for the airfare they can borrow up to 10000 from the federal government once resettled they must pay back this loan 9 gars receive settlement assistance including temporary housing referrals to other refugee programs a onetime household startup allowance and monthly income support payment under the settlement assistance program a monthly financial support is provided for each family up to one year based on social assistance rates in each province and territory it is the minimum amount needed to cover the most basic food and shelter needs 10 however many find it challenging to support their families with the income support as some must pay back the government loan for travel 11 in some cities such as surrey bc refugees are considered most atrisk for poverty homelessness and health problems as a result of the stresses and struggles of settlement after arriving in canada all refugees receive temporary coverage of healthcare benefits under the interim federal health program until the time that they become eligible for provincial or territorial health insurance this coverage is similar to what is available to all canadian citizens and permanent residents under the provincial or territorial health insurance plans it covers the costs of hospital services visits to doctors including visits during and after a pregnancy and costs of tests in addition to this basic coverage prescription drugs and supplemental services such as limited vision and dental care psychotherapy physiotherapy and occupational and speech therapy which are usually excluded from the provincial or territorial health coverage are also provided for the refugees under the ifhp the additional drug and supplemental coverage are available to refugees up to one year after settlement in canada or as long as they receive income support from the settlement assistance program or until the end of the private sponsorship although all newcomers may experience health concerns and face barriers to accessing healthcare services in canada refugees face specific challenges 12 for example refugees from waraffected countries such as somalia and rwanda and those who have been displaced numerous times are known to be especially vulnerable to posttraumatic stress and to have had limited access to premigration healthcare 1314 and as a result to experience higher morbidity and mortality rates than other immigrants postmigration in canada 15 reports indicate that most syrian refugees have also encountered considerable challenges prior to their entry into canada including war atrocities displacement and loss of wealth and personal materials 1 as in all waraffected countries women and children are particularly vulnerable 41617 they may have been at risk of or experienced abduction marriage and pregnancy at an early age sexual assault rape forced prostitution and other forms of exploitation 18 19 20 21 22 all of these experiences can affect the physical psychological and social domains of their lives previous reports have documented physical health problems such as musculoskeletal pain soft tissue injuries disfigurement and disabilities 1819 reproductive health problems such as sexually transmitted diseases chronic pelvic pain menstrual problems and unwanted andor highrisk pregnancies and mental health issues 22 23 24 according to some reports 222526 syrian women who take refuge in neighbouring countries such as lebanon and turkey often have limited or no access to healthcare after arriving in canada the social and economic realities of adjusting to a new country and language can further affect their physical and mental health needs beyond what is known about the urgent health problems experienced by syrian newcomers and the services and supports available at time of arrival there is a lack of information about health problems that may emerge over the course of their settlement and whether and how these are being addressed our study explored the health needs of newcomer syrian women in the greater toronto area their experiences in accessing health services to address these needs and the factors that have influenced their access to and use of health services the study was informed by yang and hwangs 27 analytical framework which explores disparities in the utilization of health services by immigrants in relation to four categories of factors the first category is healthcare needs reflecting alterations in health and ongoing health concerns that prompt seeking care the second category is resources ie financial and social resources that enable immigrants access to healthcare the third category includes predisposing factors such as individual demographic characteristics that affect access to and use of health services the last category represents contextual conditions that influence access to and use of services this framework guided the generation of questions asked of participants during the group discussions as well as the analysis of responses method we used a qualitative descriptive interpretive method which involves informed questioning and a reflective and critical examination of descriptive information to create an interpretive account and understanding of a phenomenon 28 we conducted the study in collaboration with key health social service and settlement community agencies serving syrian newcomers in the gta as well as with syrian community members who had lived in canada for some time and were knowledgeable about the community these stakeholders were involved in the project from the beginning and provided ongoing advice and feedback about the study protocol particularly recruitment strategies location and timing for data collection sessions and the content of the focus group discussion questions they also remain involved in knowledge uptake and dissemination activities study approval was obtained from the research ethics boards at the universities and institutions of the research team the community agencies involved in the study did not have their own ethics boards and relied on these institutional research ethics board approvals participants included syrian newcomer women aged 18 years or older who had been in canada for more than 6 months but less than one year two recruitment strategies were used first community agency staff and established community members informed syrian newcomer women they encountered about the study and provided them with contact information for the research assistant potential participants who wanted to learn more about the study contacted the ra to obtain detailed information second some participants also contacted other women in their community through word of mouth and informed them about the study the ra informed all participants about the study made it clear that participation was voluntary and that participants could withdraw from the study at any time without any consequences before focus group sessions began all participants provided written consent to take part in group discussions and for these to be audiorecorded the ra was a female graduate student who is fluent in arabic she collected demographic data from participants after receiving training she also facilitated the focus group sessions she used openended questions with probes targeting the four categories of factors identified in yang and hwangs 27 framework to explore health and healthcare concerns among participants interested participants were invited to one of five focus group sessions which were held in different locations in the gta to maximize the diversity of groups and ensure convenience for participants the ra informed interested participants about the date time and place of each focus group location interested participants arrived ahead of time to meet with the ra review the information provided in the consent form have any questions answered and sign the consent form those who agreed to participate completed a short demographic questionnaire that captured information related to their age marital status language fluency prior residence in a refugee camp and length of stay in canada in total five focus group sessions were held in different parts of the gta mississauga north york east york etobicoke and toronto east the number of women attending each session ranged from 6 to 12 each group discussion lasted 90120 min and was audiorecorded with participants consent at the end of the discussion participants were given information about local services and supports audiorecordings from the focus group sessions were transcribed and translated into english by a bilingual translator and then verified by the ra who facilitated all focus group sessions four members of the research team read the transcripts several times to gain a sense of the full dataset they then reread and coded one focus group transcript paying close attention to the explicit and implicit ways in which the participants explained their health problems in relation to their preand postmigration context following this the team reached consensus on a preliminary coding scheme which was then used to code the remaining transcripts when new codes emerged from the data they were compared with older codes to identify commonalities and variations and to develop categories and subcategories that reflected the four categories of factors proposed by yang and hwangs 27 framework data analysis ended when categories were saturated 29 results a total of 58 women aged 2160 years participated in the study at the time of data collection they had been in canada for 69 months as shown in table 2 most women were admitted through the gar program had arrived from countries neighbouring syria and were not living in refugee camps at the time most had settled in toronto or its suburbs and were married all participants were fluent in arabic about half reported that their english fluency was good or excellent and that they were enrolled in english as an additional language classes the following results are grouped by the factors related to the four categories identified in yang and hwangs 27 analytical framework need for healthcare resources predisposing factors and contextual factors need for healthcare preexisting and newemerging health needs participants spoke about direct experiences of warrelated trauma before fleeing syria including detention loss of loved ones torture and being exposed to chemical weapons and how these affected their health and the health of their family they talked about how grateful they are for the safety and security in canada i was detained and tortured in syria they slaughtered my husband i am a single parent now and canada has been great to me they gave financial support for me and my daughters and preserved my dignity i was humiliated and tortured in my own country canada has been great to me and whoever says otherwise is wrong we all went through a lot this is a new beginning for us i thank god for not being in that place again there are people who are still going through this i dont have a right to complain participants spoke about preexisting health concerns as listed in table 3 they identified a range of chronic medical conditions as well as physical disabilities for example one participant said i have diabetes and high blood pressure and on top of it my knees hurt a lot table 3 also lists new health concerns that emerged on their way to canada or after arriving in canada including medical dental and psychological problems participants attributed their psychological problems to the distress violence and trauma experienced during the war as illustrated by this quote when you come from the war you are suffering from stress and emotional pressures and it affects you physically and this is what is happening to me now i have physical problems that are due to emotional stress and pressure many participants believed that their existing andor emergent health conditions had worsened or could potentially worsen many attributed these changes in their health condition to delays in receipt of necessary care they felt the response from canadian healthcare providers was too slow to address the problems that they considered serious andor urgent for example several participants were surprised by how the emergency rooms functioned there is no emergency they let people wait like that in the hospital in the emergency room we waited till 12 midnight to be seen by a doctor and all the time i was suffering from the pain participants also reported disagreement between their selfrated health and how healthcare providers evaluated their health for example some participants felt that healthcare providers considered their concerns about certain health problems as trivial and that the healthcare providers responses to their concerns were dismissive andor too slow the following excerpts capture some of these concerns we have been here for six i have inflammation in my fingers the doctor said when your hand becomes swollen then we can take xrays i said it feels numb but she has not done anything yet my niece fell off her bicycle we took her to the doctor they scheduled an xray after three months an appointment in three months means they will see her when her bones are healed resources financial social and informational financial resources were identified as both enabling and determining factors in accessing healthcare participants spoke about how grateful they are for the financial support they had in canada but with the end of the oneyear period of government financial support and supplemental and prescription drug coverage approaching most participants expressed concerns about future healthcare cost coverage they were worried about the cost of medications seeing specialists and other healthcare services such as physiotherapy dentists and naturopathic and alternative medicine specialists social disconnection was also a key concern for most participants they were separated geographically from other syrian newcomers and were trying to find ways to connect with others who could help them with the complete settlement process most expressed the need to share resources and knowledge with people who have had similar experiences the same struggles and are from the same background one participant said i would like to hear similar stories and issues to mine the majority asked how they could become more connected to and engaged in the community how to socialize in canada and how to gain membership in social groups limited or lack of accurate and userfriendly information about care treatment and services was another significant concern for participants throughout the focus groups participants referred to unmet informational needs related to their healthcare access following migration to canada many asked the facilitator for help in addressing their concerns participants explained that back home they used to know where to go or whom to ask about who the good doctors are they missed not having a similar network in canada especially in a new environment in which they did not even understand the language good doctors are known when you live in your own country or neighbourhood you get to know where to go and who to ask where will i find this information where to go how to find it it is not easily available some participants spoke about many unanswered questions including not knowing what services were provided and by whom and what costs are covered by health insurance for example one participant said we dont have the understanding on how to deal with the health system yesterday i got to understand that we cannot go to the specialists directly maybe someone who speaks arabic can explain these things some participants used the internet to access information but many others were hindered in doing so due to lack of fluency in english limited computer literacy lack of access to computers and the internet and limited literacy overall most referred again to the fact that they had been accustomed to getting information from informal networks in syria and wanted to find similar sources in canada participants identified numerous healthrelated information needs which are listed in table 4 contributing to these financial social and informational needs participants identified the lack of proficient appropriate and timely interpretation services as a critical problem overall some even said that they no longer visited their doctors because the doctor did not speak arabic i had a few appointments for myself and children but i did not go because i felt it was a waste of time we dont understand each other even the person at the reception is not very helpful she writes the appointments on the card and i cannot understand her handwriting when i ask her to clarify she stops me not easy to see doctors due to the language barriers we dont go unless it is an emergency even the participants who spoke some english found it challenging to talk to healthcare providers i can speak a little bit of english but when it comes to medical issues i cant express myself translators were often not available at the time of appointments even when they were available there was a lack of attention to the genderspecific nature of the health concerns for example several participants spoke about male interpreters being called in during reproductive health related appointments and consequently not feeling comfortable discussing their concerns with the doctor managing the daytoday challenges involved in starting a life in a new country made it nearly impossible for most participants to learn english quickly and to a level of competence that allowed them to talk to healthcare providers they also often lacked the time and financial resources to attend english classes while taking care of young children and other family members who may be experiencing mental andor physical health problems resulting from waraffected life predisposing factors participants identified predisposing factors such as their sociocultural and immigration status which are included in the healthcare utilization framework gender also played a role in determining health and healthcare needs as reflected in how participants prioritized their familys health for example all participants talked about the health concerns of their husbands and children which they prioritized over their own in seeking and using healthcare services this idea was captured well by one of the participants who said we need to make sure that our family is ok only then we can think of ourselves many participants spoke about their husbands mental health issues emotional problems and anxieties and were concerned about how these problems may affect their future in canada they were also concerned about their childrens health problems and highlighted the many healthrelated concerns they had about their children from allergies to broken bones to dialysis participants across focus groups expressed an interest in accessing alternative medicine in canada they voiced frustration about the lack of healthcare coverage for such options as well as being laughed at andor being discouraged openly when they asked for the option to buy alternative medicines or referrals to such specialists one woman said when i was in jordan i met a pharmacist he saw my son and he asked me to use an oil on my son for his skin condition and he said you will find this in canada when i asked about this here they laughed at me and they did not help me they do not seem to respect alternative medicine syrian newcomer womens beliefs and understandings about alternative medicine has not been explored in previous studies in canada however it is commonly known that beliefs about and the value given to different forms of healthcare can affect healthcareseeking behaviour 19 contextual conditions participants tended to compare their use of health services in canada with that of syria and other countries that they had taken refuge in before arriving in canada they felt that canadian healthcare providers responses to their health concerns were slow particularly compared to what they had experienced prior to the war in syria as illustrated by the following excerpts participants referred to key gaps everything was provided fast in syria you can come anytime and get yourself fixed fast most participants were accustomed to a system that allowed direct access to specialists so they considered the inability to do this as well as delays in referrals to be a significant problem with the canadian healthcare system some had changed family doctors because they had refused or delayed referral to a specialist back home we go straight to the specialist i have different issues back pain rheumatism etc my doctor knows this he changed my medicine three or four times its been three months and a half i asked him to refer me to a specialist but he refused saying that i do not need a specialist i have issue with my gall bladder it has a stone i had a crisis they took me to the er they asked me to go to the family doctor so he can refer me to a specialist but the family doctor said that he cannot refer me the family doctor was supposed to refer me but it took him a long time so i went to another clinic and now they have scheduled an appointment with a specialist the government settlement program placed immigrants in suburbs or other areas without access to public transportation which was identified as a main barrier to healthcare utilization participants said that the time needed to get to appointments and unfamiliarity with the public transit system affected their use of healthcare services the doctor is based in downtown and it is such a long commute it is not easy in order for me to reach the doctors clinic i need to take many buses i like my doctor i take 3 buses to reach her clinic you know how much time it takes when the facilitator asked whether participants had considered finding a doctor closer to their home one woman responded it is not easy to change a doctor easier said than done did you forget that i am a newcomer discussion previous research both within and outside canada has identified some health concerns among syrian refugees 3031 and proposed guidelines for initial assessment and management of communicable and vaccinepreventable diseases in refugeereceiving countries 27 32 33 34 35 36 for example the canadian collaboration for immigrant and refugee health guidelines 1637 specify the need to focus on identifying diseases such as tb hepatitis b hiv and intestinal parasitic diseases however most studies within and beyond canada have not focused on newcomers expressed health concerns especially beyond the immediate postarrival period this is one of the first studies to examine the health concerns of syrian newcomer women who have been in canada for less than one year and were admitted to canada primarily through the gar program although gars constitute only about half of the syrian refugees admitted to canada they are the ones most dependent on and likely to come into contact with settlement service providers early in their settlement period gars are more reliant on multiple and multilevels of service providers unlike the psrs and bvors who have their sponsor groups support and help in navigating the system during the early settlement period like many of the refugees fleeing syria 1 some of our participants and their families had lived in refugee camps in the countries neighbouring it including jordan lebanon and turkey before arriving in canada some had experienced detention torture and loss of loved ones they talked about valuing the feeling of safety and security in canada and were grateful for the support from the canadian government as they shared their experiences it became clear that they have shown great resiliency in the face of intense hardships and continue to do so by coming forward to seek ways of improving their lives in the postmigration context in canada syrian newcomer women like many other newcomers to canada have both general and immigrantspecific health needs 12 our participants said they had experienced delays accessing healthcare services due to lack of culturally responsive and linguistically appropriate information about the healthcare system notably their healthcare service utilization appeared to be influenced by the discordance between selfreported health and how it is evaluated and responded to by healthcare providers additionally participants had certain prearrival perceptions and expectations about canadas healthcare system which were not met by their actual experiences with the system their healthcare providers and the nature of healthcare services provided and received they were surprised by the limited information available about mental health services dental care eye care specialized services for children as well as services related to reproductive health pregnancy and childbirth some of these concerns may be related to poor communication on the part of healthcare providers in explaining their rationale for time taken for referrals and diagnostic tests for example if hba1c is normal and if there are no other related concerns an eye examination might not be a priority in relation to other health concerns and medication reordering may have been done through a pharmacy they also referred to information gaps at the broader systemslevel with regard to access funding referral and followup predisposing factors such as gender immigration status premigration experiences and length of stay in canada appear to intersect with contextual conditions to shape health service utilization experiences among our participants access to healthcare was shaped by the available resources receiving health insurance encouraged health service utilization while social disconnectedness and the lack of appropriate and adequate language resources in particular prevented it participants identified isolation language barriers not being connected with arabicspeaking healthcare providers lack of serious attention to their health concerns and slow followup and referrals as key reasons for their declining health status with the end of the oneyear period of government financial support and the supplemental and prescription drug benefits coverage period approaching many participants had fears about the future specifically finding work learning english supporting their families and accessing health social and settlement services informal networks of friends families and ethnic and religious communities are known to bridge language barriers mitigate mistrust of the system and also act as a buffer against the harmful effects of stress during settlement 3839 a similar protective network has not be available to syrian newcomers given the rapid settlement process that dispersed families across the different parts of the gta and beyond creating a considerable disconnect from each other many of the advocacy groups nonprofit groups and settlement services that responded to the initial call to action for receiving syrian refugees into canada have not had the financial or social resources needed to continue their work beyond this initial period provinciallevel refugeespecific resources and networks may be unable to provide support to refugees and their integration into the healthcare system beyond the initial settlement period 4 conclusion together the results of this study point to the need for a broader understanding of refugee health needs beyond a simple examination of premigration risks or a focus on the cultural determinants of healthcare seeking behaviour beyond efforts to address the immediate health needs of syrian refugees it is crucial to develop a multisector coordinated approach that takes the many layers of health needs resourcesbarriers predisposing factors and social and structural conditions into account our study demonstrated the usefulness of an analytical framework for not only understanding healthcare access experiences and mapping the different elements of it but also exploring the way in which predisposing factors such as gender immigration status premigration experiences appear to intersect with contextual conditions to shape health service utilization experiences similar theoretically informed studies could be useful in better understanding the settlement experiences and healthcare utilization among not only syrian refugees but other newcomers and refugees across a larger timespan in other areas in canada this will contribute to an evidence base in support of a broader inclusivitydiversitybased approach to newcomer settlement policymaking in canada authors contributions sg is principal investigator and led the project upon which this paper is based conceptualized and designed the research project data collection methods and study instruments involved in the data analysis and interpretation of the findings ss provides methodological expertise to the project conceptualized and designed the research project data collection methods and study instruments involved in the data analysis and interpretation of the findings vi conceptualized and designed the research project data collection methods and study instruments involved in the data analysis and interpretation of the findings ry conceptualized and designed the research project helped to recruit participants and trained and guided the data collection hb conceptualized and designed the research project helped to recruit participants and trained and guided the data collection ja provided expertise in the area of refugee settlement mr provided expertise in the area of refugee health and settlement sf involved in the data analysis and interpretation of the findings all authors revised and edited the manuscript critically for important intellectual content of the material all authors approved the final version of the manuscript competing interests the authors declare that they have no competing interests

objective access to healthcare is an important part of the re settlement process for syrian refugees in canada there is growing concern about the healthcare needs of the 54560 syrian refugees who were admitted to canada by may 2018 80 of whom are women and children we explored the healthcare needs of newcomer syrian women their experiences in accessing and using health services and the factors and conditions that shape whether and how they access and utilize health services in the greater toronto area gta method this communitybased qualitative descriptive interpretive study was informed by yang hwang 2016 health service utilization framework focus group discussions were held with 58 syrian newcomer women in the gta these discussions were conducted in arabic audiorecorded with participants consent translated into english and transcribed and analyzed using thematic analysis results participants health concerns included chronic longterm conditions as well as new and emerging issues initial health insurance and coverage were enabling factors to access to services while language and social disconnection were barriers other factors such as beliefs about naturopathic medicine settlement in suburban areas with limited public transportation and lack of linguistically culturally and genderappropriate services negatively affected access to and use of healthcare services conclusion responding to the healthcare needs of syrian newcomer women in a timely and comprehensive manner requires coordinated multisector initiatives that can address the financial social and structural barriers to their access and use of services

introduction societal and economic developments such as demographic change changing values increasing academization and skills shortages have led to a war for talent this battle for the best challenges human resource management to achieve strategic competitive advantage in an increasingly dynamic business environment moreover firms need to invest in human capital to increase their value given this fact and the need to be an attractive employer employer branding has gained importance in recent years employer branding has already proven useful in many industries in tourism firms it was found to be particularly relevant for to respond to an increasing labour shortage the migration of welltrained workers to other industries and high turnover rates especially since the recent pandemic crisis the intangible service nature of tourism products their small and mostly familybased industry structure and specific structural constraints make it difficult to position oneself as an attractive employer family businesses play a crucial role in the economies of many nations around the world as they have been able to hold their own for decades in the dynamics of economic structural change especially against the process of concentration and in the globalization process employer branding of family businesses is hence a special case as the family is the dominant group exerting influence on the business family businesses not only have a corporate identity but also a family identity this interrelationship creates a distinctive organizational identity as a unique resource focusing on the organizations family identity can be helpful in developing unique brand strategies for example communicating family values and qualities can be a persuasive argument to employees which is particularly interesting for small and mediumsized enterprises vallaster et al show that entrepreneurs have a diverse understanding of employer branding and integrate it differently in their firms eventually every firm has an employer brand because when someone talks writes thinks or remembers a firm as a place to work the employer brand comes to mind thus also every tourism firm has an employer brand but the question is whether the brand also works in favour of the firm and how furthermore research shows that many labour problems are homemade due to inadequate leadership principles and inadequate hrm compared to other service industries where a systemic and strategic approach to hrm is already widespread as a consequence this paper targets to explore these multifaceted challenges by a qualitative study with managers successors and hr managers in the tourism industry setting our findings show how employer branding can benefit tourism firms in order to attract and retain managers but also what expectations professionals have to their employer literature review 21 employer branding employer branding is defined as a longterm strategy for the perception of already established and potential new employees as well as other stakeholders who are in contact with a particular firm tanwar and prasad also recognize that employer branding is much more than a tool to attract potential employees it can also be seen as a retention measure for existing employees employer branding can create a clear employer brand position visàvis competitors and prospective employees in the workplace thus through such a package of functional economic and psychological benefits a workplace considering the firms philosophy can be provided employer branding is used to define an identifiable and unique employer identity it also provides an idea of what the employment relationship in the organization will be like bichler et al suggest that companies need to rethink employee retention in terms of meaningfulness not only in the recent times of crisis according to moroko and uncles the following three characteristics apply to a successful employer brand be recognizable and noticeable come across as relevant and resonant and be different from direct competitors this means that achieving brand awareness and communicating clearunambiguous value propositions and differentiation from brands are important for ongoing success employer branding in tourism working in the tourism industry brings positive attributes however people are often confronted with the disadvantages in this line of work not realizing the fringe benefits offered although the tourism industry has experienced positive economic growth in recent years stakeholders complain about an increasing lack of qualified and motivated employees high turnover rates and the migration of welltrained workers to other industries as well as low barriers to entry for nontourism trained employees this development is not only due to societal factors but also to specifics of the industry which presents itself as an attractive employer this situation is influenced by the seasonal small and family business structure of the industry the service character of tourism products as well as specific structural framework conditions which on the one hand increase the personnel intensity and on the other hand lead to a poor employment image of the industry this poor tourism employment image find its base on crosslevel dynamics of radicalization and attenuation that supports such negative image construction making it drastically more difficult to recruit skilled workers to improve the industrys image promoting the labour benefits offered could be a valuable approach that requires the support of the whole organization in addition to the efforts of the hr department in addition research shows that seasonal and resident workers have different needs and can be motivated by diverse factors which poses an additional challenge however the shortage of skilled workers can be compensated by the deployment of family members for example by making more flexible working arrangements and adapting their own lifestyle to the firm at this point the phenomenon of black sheep must also be mentioned this refers to those tourism firms that do not focus on appreciation towards employees however these are precisely the businesses that repeatedly appear in the media through negative reports many of these stories are partly cliché but in fact many of these negative phenomena are based on a misunderstanding and lack of training in personnel management employer branding in family businesses in tourism hrm in family businesses in tourism is peculiar attracting and retaining employees with the right skills knowledge and attitudes is challenging the overlap between family and business in particular leads to a volatile situation in general human resource strategies the majority of human resource policies are shaped by family managers as a result they are shaped by family internal norms and values thus the maintenance of family ties plays a central role in determining human resources work in family businesses moreover there is a link between family and business growth family businesses can have a more positive work climate higher levels of involvement trust and commitment exposing employees to strong family influence kallmuenzer et al imply that tourism firms should among other things know their business environment well and build on the skills and experience level of employees as key factors for company performance hence the development of familyoriented working relationships characterized by warmth friendliness and intimacy as well as a professional approach to strategic hrm could contribute to the financial performance of these businesses while other industries systematized their strategic hrm years ago the tourism industry only recently began to advocate for a more strategic approach baum in his overview of the changes in human resources in hospitality and tourism in recent years and the current key issues in the industry notes that progress towards more mature fair and respectful strategic human resources management in hospitality and tourism has been slow the small and mediumsized structure of family businesses in the tourism industry leads to disadvantages in terms of employer branding compared to strong brands unknown smes convey a limited sense of prestige to employees in addition these businesses lack training opportunities as well as aggressive communication regarding their advantageous characteristics and are also hardly flexible in terms of working hours considering these disadvantages some tourism businesses use their location to position themselves as attractive employers the reason for this is that the attractiveness of the firms location can have an influence on the perception of employees these firms are valued for familylike personal and authentic relationships between employers and employees low internal power structures and limited corporate politics but they also have great potential to develop unique employer promises these specific characteristics of family businesses offer ideal conditions for combining economic performance with human values family businesses are predominantly able to develop unique brand strategies because they are able to integrate the family identity of the business and its different attributes family identities are intangible firmspecific unique inimitable and identifiable they also personify firms externally in the marketplace through familybased brand identities and associated positive associations family businesses can gain an advantage over nonfamily businesses and thus differentiate themselves from a wide range of competitors family businesses enjoy a reputational advantage due to the family being an integral part of the business they project a positive image associated with values such as sustainability reliability authenticity credibility humility and respect in contrast to anonymous impersonal firms family businesses are authentic personalities and guarantee stability and high quality with their name however stakeholders may also ascribe negative attributes to family businesses some family businesses choose to hide their identity as a family business and refrain from presenting themselves as a family business thus the extent to which these businesses express their family ties varies depending on the degree of family business pride community social ties and longterm orientation family businesses in particular are encouraged to effectively use their family ties to develop family brand equity or reputational capital due to a lack of economies of scale and scope this allows for improved business performance which has already been recognized by some family hotels in the alpine region they use their family names to represent the high service quality of their offers in this way they show that family businesses in the tourism industry can also build strong brands with a special emotional added value based on personal relationships between family and staff or customers it is more difficult for smaller family businesses in particular to achieve a certain level of recognition as an employer job advertisements in particular offer an important but neglected tool for promoting the employer image according to petry at al the signalling effect of a job advertisement is strongest when it combines an exciting and challenging description of the tasks with potential career opportunities in addition to information about the company and of course the salary the presentation of the family name personality and family business history can lead to further competitive advantages enhancing family businesses through employee appreciation plaikner suggests that family businesses strong sense of regional social responsibility their longterm and sustainable orientation and the reliability and high regard for employees associated with the entrepreneurial family are decisive factors in creating a strong employer brand employee appreciation has the potential to stimulate what these family businesses require committed employees oriented to passion and a drive towards the family values und shared vision although family businesses are valued for their familial personal and authentic employeremployee relationships low internal power structures and limited corporate policies they have great potential to develop a unique employer promise this strengthens their regional positioning in particular visual and textual cues are used to communicate for example the values and image of family businesses according to schollgrissemann et al tourism destinations in particular should promote their family business composition this is not only key to positioning family businesses more strongly in the market but also in the labour market facing a shortage of skilled workers according to breier et al digital marketing focused on hospitality and family values creates a feeling of trust and attracts qualified employees through an appreciative attitude especially in times of crisis the direct effect of family business image promotion on perceived brand authenticity underpins the notion that family businesses can leverage a strategic competitive advantage by communicating their family nature to the outside world the role of women in employer branding another key aspect to consider for the development of family businesses as employer brands is the role of women in most societies the status of women in business has greatly improved in the 20th century nevertheless limited access to positions of power as well as subordination are often still evident but the number of women in leadership positions is increasing carli eagly emphasize that there must be a balance between male and female power therefore women must be represented in large numbers this requires role models and mentors for potential female leaders to develop leadership mentalities women in leadership positions can face numerous obstacles throughout their careers in particular reconciling career personal ambitions and motherhood poses significant challenges for women this is because career advancement has a negative effect on family relationships and personal wellbeing for example historical examples and role models also lead women to believe that holding leadership positions creates deficits in other areas of life in addition the stress level is further increased by dynamic leadership positions in order to reconcile career and private life chisholmbruns et al recommend that firms offer more flexible working time models allowing women to be more involved in leadership positions equal pay for equal work also plays a central role as women are disadvantaged by the difference in pay between men and women this difference in particular makes leadership positions less desirable for women because of this even greater deficits in female leadership emerge in the tourism sector in particular the majority of female employees are overrepresented in lowpaid parttime and casual jobs and underrepresented in management positions this study is therefore also particularly interested in exploring the role of women in the development of an employer brand of tourism companies and especially in family businesses which is still underresearched both in practice and in the literature method a qualitative research design was chosen for this explorative study to develop a better understanding of the factors that lead to the development of a stronger employer brand in the tourism industry semistructured interviews were used as a means of data collection this type of interview enables insights to be gained into the narratives and direct quotations of the interviewees regarding their attitudes beliefs thoughts intentions actions and experiences for the interviews a guideline was developed in advance based on the previously researched literature table 1 overview of the regions and their surveyed employers and employees 28 interviews with managers successors and hr managers of tourism businesses took place in 2018 in all seasons in firms in various tourism regions of tyrol austria the regions are divided as follows kitzbühelkufstein schwaz innsbruckland imstpitztal st antonserfaus and osttirol the interviews lasted 48 minutes on average in addition to the employers employees were also interviewed in order to reveal the perceptions of employers and employees for this purpose 9 employees in east tyrol were interviewed this region is highly significant precisely because of the different regional development the sample size for both employers and employees was determined using theoretical saturation in doing so interviews are conducted until sufficient usable data is available and no more new insights can be acquired theoretical saturation was reached much earlier for the employees with 9 interviews whereas this was only achieved for the employers with 28 interviews after completion of the interviews the interviews were transcribed and divided into categories with the help of a coding framework derived from the guideline the interviews were analyzed using qualitative content analysis with technical support from maxqda the formation of the categories is based on mayring and the coding on kuckartz figure 1 shows the individual categories into which the respondents statements were divided and with which the results were derived in addition six expert interviews were conducted with female participants in leading positions in tourism firms in 2021 to explore the specific role of women in employer branding employer branding requires role models and mentors for potential female leaders to develop leadership mentalities female experts that have sufficient management responsibility and were characterized by the fact that they arewere all directly confronted with the issue of familywork balance were recruited the time lag of interviews between 2018 and 2021 had the advantage of also including the coronavirus pandemic which was particularly significant for the labour issue in the tourism industry the time lag allowed to include perspectives before and after the first peak of the corona pandemic while the specific female view allowed for variance the average duration of the interviews was 36 minutes the evaluation of the conducted expert interviews was carried out in the same way as the evaluation of the interviews with employers and employees figure 2 shows the respective categories from the expert interviews results contextual external factors the majority of the interviewed entrepreneurs see their current position with regard to employees as positive because of their permanent employees the same is perceived by the employees in particular the relationship with the employer and the working conditions are valued nevertheless entrepreneurs repeatedly encounter negative undertones when looking for new candidates the results particularly point to a lack of interest on the part of local workers therefore firm are forced to neglect their strategies and further development according to agk g their positioning is fine for what we offer our guests but to develop further it clearly needs more the current situation of a business is also influenced by its size not only smaller but also larger enterprises can have both advantages and disadvantages for example the size of the firm can influence the following factors closeness of employeremployee relations family atmosphere of the firm flexibility of working hours and financial resources firm size is crucial for employees perception of the business as the type of workplace depends on employees preferences this is something individual the bigger the firm is the more organization is needed ie working hours division of labour its all organized not everyone likes that they want individuality small family structures where everything is flexible the interviewed entrepreneurs attach particular importance to a positive image as an employer especially in their own region a good reputation enables the promotion of positive word of mouth which potentially attracts new employees that is why it is actually important to be positioned externally as a good organization then you have won half the war then people come and ask and organize among themselves similarly most firms see a high level of regional social responsibility this concerns for example the creation of jobs the decision for village life and the development of infrastructure or the reduction of rural exodus the large number of tourist job offers and a small number of local workers may also lead to a low level of regional social responsibility on the part of enterprises regional cohesion and the integration of all stakeholders is seen by some family businesses as crucial to the success of the whole region i think our region lives from tourism and therefore we certainly have a certain social responsibility also in terms of making young people feel comfortable in our region so that they can identify with the whole apart from the shortage of skilled workers a poor industry image seems to be the most frequently discussed issue in the tourism industry seasonal businesses may be more affected than yearround operations unhealthy employeremployee relations can also lead employees to take advantage of their position of power this creates additional pressure through price wars for the best workers and i think if i tell a waiter that he is not doing well it doesnt attract him to stay because he can easily find a new job and maybe they pay even more understanding employer branding the majority of entrepreneurs have heard of employer branding but their understanding of the term is fragmented in contrast the employees surveyed have never heard of this term the interviewed firms already implement measures that are to be seen as part of employer branding this is often not entirely clear to them on the one hand there is an identityoriented understanding of employer branding starting with the internal quality as an employer up to aspects such as common organizational culture or deep employee identification on the other hand the function of employer branding as an external communication tool to increase awareness and to project a desired external image as an employer is emphasized in this case there is an assumption that employer branding is closely related to social media and the internet some of the employers interviewed suggested that employer branding is only feasible for larger firms most firms place great emphasis on providing attractive workplaces and actively seek to improve and publicize their high quality as employers therefore the actual implementation rates of employer branding as defined for this study seem to be rather low the reasons seem to be closely linked to their sme structure its getting really complex sure you can do a lot with your employees but where does it end and where does it start i think considering how big our firm is its enough if we manage to give our employees that personal touch and that someone is there for them if there is a problem measures to recruit retain and motivate staff family businesses in the tourism industry are currently taking a wide range of measures to recruit retain and motivate staff as well as to implement employer branding effectively these measures include activities in both performance and communication policies employees take notice of these efforts as they are aware that measures are being taken to make the firm more attractive measures include leisure activities such as hiking skiing tobogganing and excursions as well as celebrating or eating together however for family businesses general aspects seem to be essential in addition the personal relationships that are shaped by family values represent the greatest potential to be communicated for the employer attractiveness of family businesses the family working atmosphere and the management of the firm as a large family are mentioned as important factors for positively influencing the behavior of employees they are actually part of the family for me trying to run the house like a big family and dealing with the staff and making sure my staff are doing well is my main job while communicating family values and qualities can have a positive impact on employees not all respondents relate equally to their family ties nevertheless respondents feel it is essential to emphasize values agk k states that everyones need is for someone to say you did a good job today that was perfect today this is seen by employers as more motivating than small monetary rewards furthermore strategic hrm measures should focus on many diverse areas although fair remuneration salary and regulated working hours are seen as basic requirements these are not the most important factors for the wellbeing of employees therefore the staff rooms are designed to make you feel right at home significance of employees the views of the entrepreneurs interviewed regarding the importance of implementing employer branding or strategic hrm in family businesses in the tourism industry vary widely some businesses recognize that a systemic approach to strategic hr management is critical to adequately address the current labour market situation other businesses however question the need for strategic implementation of employer branding this is mainly done by smallstructured firms that fear an increasing complexity of strategic hr management due to employer branding and prefer to focus on human factors and their gut feeling even if the development of a strategic employer branding concept does not seem important to firms the high importance of employees is generally recognized firms see their employees as the most important resource who are of immeasurable value to their success according to the entrepreneurs it is necessary to get along with the staff and work together in order to retain them in this respect fair and respectful treatment is important to employees that the staff are treated fairly in any case that you are competent that you can talk to the boss especially if something doesnt fit or something has happened that you always dare to say anything if something has gone wrong or something like that furthermore the implementation of employer branding and strategic hrm is linked to certain financial aspects employees are a significant expense item due to the high costs in addition to the normal salary the high nonwage labour costs and an increased price war for particularly qualified employees nevertheless the interviewed firms state that employees are not to be seen as a burden but as a source of profit thus investing in them is not to be seen as a waste positive impact of wordofmouth advertising firms quite frequently mention the positive effects that result from wordofmouth advertising by internally satisfied employees for example agk n states that we are known as a good employer but we have just found out that we have already received some applications for the summer season from employees who work in other hotels here in st anton or lech this is in a way a good feedback it is also evident from the interviews with the employees that the measures taken by the firms are successful on the one hand it is stated that employers make a great effort in the context of an employment relationship and that this ensures satisfaction on the other hand it is also perceived that employers make efforts to find new employees via platforms and media furthermore it can be stated that firms are offering more and more additional services for employees what an effort she actually does everything what wishes if you have wishes no matter whether its workwear or something else everything is implemented by her and we get everything from her so its very atypical for our sector and thats just really great with us in the business with the boss yes the role of employees for reaching performance targets family businesses see financial performance as a necessary prerequisite for business continuity but tend to evaluate their success in terms of stakeholder satisfaction in this regard agk b states that we dont always do things for financial reasons we do a lot out of conviction in particular the satisfaction of the guests leads to a high occupancy rate and thus many overnight stays secure jobs you hear it from the guests themselves that everything is just perfect that they are super satisfied with us you also notice that because some of them have been coming here for tens of years since the day we opened theyve been coming to us every year maybe once in summer and once in winter the visible effort on the part of employers to ensure satisfaction is noted positively in addition fair and respectful treatment is central for employees therefore all interviewed employees are convinced that increasing the attractiveness of tourism employer brands is of great importance a credible example on the part of the employer is important women in tourism management positions for the specific focus of the role of women in employer branding in tourism results extend the general findings spending time with family and friends on weekends shows to be of high priority however this is a challenge for workers in tourism as days off do not automatically fall on saturday and sunday some form of separation between work and private life is necessary to create a balance between these two areas of life in addition for the majority of the experts childcare facilities at the workplace are important but difficult to implement in smallstructured businesses nevertheless mothers can be supported by this offer another important factor for a longterm successful employment relationship between employer and employee is the agreement on values the reason for this is that professional activity takes up the majority of ones life it is important that the values are communicated and known so that they are appreciated as they are described as a key attraction factor in addition for three out of six female experts interviewed the familyfriendliness of the firm is relevant when choosing an employer this is because the willingness to be familyfriendly has an influence on ones own image of the employer organization career options within a business are perceived as important by the respondents but personal development is in the foreground small firms offer opportunities for codetermination as this can be attributed to the smaller structures this allows employees to get personally involved with regard to further training ex6 would like financial support if it is professional further training from which the business also benefits ex2 and ex3 state that further training should be integrated into working time the interviewees state that employee training has a positive impact on firm efficiency as the time invested leads to improved work performance openmindedness cooperation and motivation on the part of employees are also needed however the experts also consider the exchange within the team to be important in order to improve communication and interaction with each other in addition to the ability to work in a team social commitment is also important this commitment increases the attractiveness of a firm it is important that the business does not go against social and economic norms social commitment does not only refer to the firm and its stakeholders and the environment but also includes moral and ethical obligations in dealing with employees discussion employer branding resources and networks interpreting the results from the qualitative study principles from the resourcebased view can be seen the success of a business depends on its capacities and resources firms that can use these more efficiently can differentiate themselves better and remain in the market in the long term and sustainably as a result it can be assumed that smaller firms have difficulties in achieving specific goals and implementing growth as they have less capacity and resources thus it can be assumed that smaller firms have disadvantages in implementing employer branding compared to larger firms this assumption can also been in the study results statements from smaller firms clearly indicate that larger firms have an advantage in terms of providing resources for employer branding nevertheless in order to compensate for the aforementioned deficits in capacities and resources resources of family members working in the business are used results also reflect assumptions from the networkbased view as a part of the resourcebased view findings show that almost all firms use their own employees as well as their other networks to recruit new employees for vacancies family businesses in particular have networks outside the firm that can be used for the firms purpose networks therefore play an important role for the samples firms when it comes to employer branding the larger the network the easier it is to find suitable employees for ones own firm and to market it as an attractive employer employer branding and firm size when consider the specific role of the often small firm size in tourism especially in rural areas it cannot be concluded from the data that this is a key factor for the implementation of employer branding all of the firms surveyed are aware of employer branding and initiate selected measures for this purpose the smaller the business the more efforts must be made to position itself as an attractive employer these firms generally have fewer capacities and resources that they can use for employer branding measures however this shortcoming is compensated by the fact that the family uses its own as well as its employees networks employer branding and location employer branding efforts also depend on the location of the business tourism businesses outside of urban centres and cities are less attractive for potential employees which makes recruiting new staff more difficult east tyrol in particular underlines these results in the sense of a model region as the comparison of urban centres to remote side valleys provides ideal conditions firms located in such areas have to take significantly more efforts or work with other arguments and incentives in order to be attractive and to attract applicants for tourism enterprises in rural areas the implementation of employer branding is much more difficult than for enterprises in urban regions however they possibly could offer a more sustainable lifestyle to bring people back to rural areas this also requires a modern and familyfriendly infrastructure employer branding and corporate values both the corporate culture and the corporate values are of essential importance these are not only essential factors for a successful internal and external transfer of business but also contribute to the perception of a tourism business as an attractive workplace values determine the motives according to which individuals act and if this action becomes a selfimage then this has a positive influence on the firms success sustainably oriented entrepreneurs cultivate a fair communication culture and show a willingness to compromise and cooperate these aspects are perceived as important especially by employees in family businesses in this context family cohesion is also worth mentioning this gives employees a sense of a stable internal environment furthermore respect is of great importance for employees according to borowski and karnes respect seems to be the most important driver for employees to commit to the business accordingly employees in family businesses are much more exposed to family influence than in nonfamily businesses this cohesion leads to increased employee identification with the business lower absenteeism and voluntary extra work by employees thus increased productivity can be realized employer branding and women in senior management positions in particular employer branding measures that an increased worklife balance leads to positive results for employees in the view of the interviewed female managers as they are much more motivated to give top performance in addition offering familyfriendly benefits in their view has a positive impact on employee engagement in addition to this offer workers seem to also value longterm opportunities for further development and thus inhouse career options and promotion opportunities which have a positive impact on organizational attractiveness however it is difficult for firms to offer continuous training while still needing to be innovative conclusion this study contributes a deeper understanding of the important role of employer branding in tourism family businesses to address the challenges from the war for talent from this perspective the identity and valuebased selfimage of a business forms the basis for building an authentic and meaningful employer brand family businesses particularly present in tourism and faced with the great challenges of a high turnover rate seasonality and further issues form a unique context with the potential to give their employer brands a special meaning this can be enabled by integrating family values and qualities into business and brand strategies as the findings of this study show the employer brand or employment offer builds on both tangible and intangible reward features study results show numerous practical measures that could be implemented within the businesses both in the area of performance policy and in the area of communication policy however these measures should be adapted to the individual situation of the firm as there are significant differences in the possibilities and available resources of organizations of different sizes while many firms already invest in tangible benefits for their employees intangible aspects knowledge of modern and participative leadership as well as professional experience are essential to counteract the current shortage of skilled workers and the poor employment image of the sector to explicitly integrate family elements family businesses in the tourism sector have the opportunity to emphasize their familiarity and harmonious family working atmosphere to treat employees like family members and to cultivate amicable relationships and mutual respect this can also ensure employee satisfaction which in turn has positive effects on the one hand a high level of satisfaction leads to a higher identification with and attachment to the business which also results in a higher willingness to perform on the part of the employees on the other hand satisfied employees are also perceived as such by the guests this leads to employees passing on their satisfaction to the guests which in turn leads to more overnight stays and more turnover and profit the results show how important an appreciative attitude and interpersonal trust are for employees especially when it comes to employer branding in familyrun companies the central meaningful corporate values the type of cooperation within an organization and the handling of the central corporate resource of employees can play a greater role than monetary incentives and should not be neglected in the weighting of employer branding strategies this finding is important as small businesses which are strongly represented in the tourism sector often do not have the capacity for intensive employer marketing the dimensions of further training team spirit and parttime careers for managers discussed with the experts should also increasingly address the needs of female managers in employer branding in the tourism sector in connection with this a central aspect should also be placed on the compatibility of family and career and transparent communication regarding future options as a mother and father within the company should be encouraged social stereotypes also make it difficult for men to reconcile their role as a father with their professional obligations and this should not be neglected with regard to equality in the professional world regional measures such as improving childcare in tourism destinations or companyfinanced childcare facilities as is already practiced in one surveyed destination can make it easier for employees to return to work and tap into this important potential for the sectoral shortage of skilled workers in tourism destinations in particular it is important to support qualified professionals in a longterm and appreciative manner basically all firms apply certain employer branding measures whereby remote and not so wellknown regions have to make greater efforts to be successful therefore there seems to be a relationship between the use of employer branding and the type of region what will also play a role in the future is to what extent tourism associations and regional managers recognize the great potential of building up regional employer branding adapted to their member businesses as with every research also this study is not without limitations due to its qualitative nature the identified factors for employer branding in tourism might be contextspecific and should therefore be explored in other cultural settings moreover the study findings are explorative in nature the identified factors could thus be tested on a larger sample in a quantitative study to possibly develop measures for employer branding

a fierce war for talent has emerged particularly in the tourism industry with labour shortages and high turnover rates this situation challenges employers to secure strategic competitive advantage through their most vital asset people simultaneously firms must invest in their human capital to increase their value heightening the significance of employer branding this paper hence investigates employer branding and does so in the unique context of family businesses the dominant form of tourism firms where employer branding takes on a distinct dimension as the familys influence fuses corporate and familial identities extending prior research findings that indicate that labour issues often stem from leadership inadequacies and human resource management shortcomings this paper aims to comprehensively examine these multifaceted challenges and their relevance in the tourism industry this study employs a qualitative approach utilizing 28 semistructured interviews with managers successors and hr managers in tyrol an established tourism region in austria and europe the results reveal that the integration of family values and qualities as well as the identity and valuebased selfimage and brand strategies of a business are important factors in recruiting and retaining employees this study contributes to deeper insight into the importance opportunities and challenges of employer branding in familyrun tourism businesses

introduction the emergence of research collaboration networks has largely contributed to the development of many scientific fields and the exponential increase in research publications 1 scientific collaboration is described as the interaction occurring between two or more entities to advance a field of knowledge by uncovering scientific findings in more efficient ways that might not be possible through individual efforts 23 collaborative relationships affect research performance by disseminating the flow of knowledge improving research capacity enhancing innovation creating new knowledge sources reducing research cost through economies of scope and creating synergies between multidisciplinary teams 2 4 5 6 7 therefore understanding the status quo of a scientific discipline requires understanding the social structure and composition of these collaborative relationships 189 social network analysis is one of the most utilized methods for exploring scientific collaboration networks sna can quantify analyze and visualize relationships in a specific research community identify central opinion leaders that are leading collaborative works as well as evaluate the underlying structures that are influencing collaboration usually in a scientific collaboration network the authors institutions and countries are referred to as actors or nodes and the collaborative relationships between them as ties indeed there are a plethora of studies that used sna to examine scientific collaboration networks of coauthors in various disciplines 2 10 11 12 13 14 15 16 17 18 however the findings of the above studies remain inconclusive regarding the longitudinal associations between structures of coauthorship networks and research performance across different subperiods 18 19 20 and particularly in the stakeholder theory and management field there is paucity of evidence the value of the stm discipline in scientometrics and scientific collaboration research lies in its crossdisciplinary nature ie having been applied in various business 2122 and nonbusiness domains 23 24 25 interconnecting different scientific disciplines that were once considered dispersed the stakeholder theory is considered by many as a living wikithat is continuously growing through the collaboration of various scholars from different research fields in light of the above argument the aims of this study are to 1 explore the evolution of research collaboration networks of each of the authors institutions and countries in the stm discipline and across three consecutive subperiods 2 identify the key actors that are leading collaborative works in each subperiod and 3 understand the longitudinal effect of coauthorship networks on research performance measured by research productivity and citation counts of the entities 26 certainly scholars can collaborate in a multitude of different ways ranging from facultybased administrative works conference participations meetings seminars interinstitutional joint projects and informal relationships 27 however this study uses coauthorship analysisas a widely used and reliable bibliometric method that explores coauthorship relationship on scientific papers between different actors being authors institutions or countries therefore the analysis in this paper is carried out at three level the micro levelauthors of the same or different institutions the meso levelinterinstitutional strategic alliances and the macro levelinternational partnerships entailing the authors and institutions all of which are major spectrums of research collaboration 728 to do so the web of science database is used to extract the bibliometric data of 6127 journal articles published in the last 32 years this data was analyzed using bibexcel as a package program for bibliometric analysis ucinet for further sna and vosviewer for visualizing the networks the results provide important insights for allocating governmental funding maximizing research output improving research community reputation and enhancing cost savings that all should be directly or indirectly piloted by the most suitable scientists that can influence and lead collaborative research in their networks 2930 this paper starts with a brief history of stm research followed by an overview of network theories most relevant to this study then the methodology for data collection refinement and analysis is described descriptive and sna results are presented for each of the examined networks across the three subperiods followed by the findings of the association testing between different social network measures and each of the citation counts and research productivity metrics lastly the conclusions and the theoretical and practical implications are provided literature review origins of stm the stakeholder concept was first originated in the stanford research institute in the 1960s and then more formally introduced by freeman 31 as a new theory of strategic management that aims to create value for various organizational groups and individuals to achieve business success the stakeholder theory aims to define and create value interconnect capitalism with ethics and identify appropriate management practices 32 a stakeholder is best defined as any group or individual who can affect or is affected by the achievement of the organizations objectives 31 freeman emphasized on the relationships between the organization and its stakeholders as the central unit of analysis and a point of departure for stakeholder research accordingly rowley 33 was the first to introduce social networks to stm to understand the mechanism of such relationships in particular he argued that a focal firms response to stakeholder pressure is based on the interplay between the centrality of the focal firm and the density of stakeholder alliances there have been many seminal works that put stakeholder theory on a solid managerial science footing such that of donaldson and prestons 34 that conceptualized the theory from a descriptive instrumental and normative approach followed by mitchell et al 35 who proposed a framework for identifying stakeholder salience using the attributes of power legitimacy and urgency and so on 36 37 38 39 expansion of stm from the early 2000s stakeholder theory has shown to be a class of management theory rather than an exclusive theory per se by its applicability in various business domains such as business ethics 40 41 42 finance 43 44 45 accounting 4647 marketing 224849 and management 215051 afterwards the interest has moved to stakeholder analysisa main systematical analytical process for stakeholder management that involves identifying and categorizing stakeholders and identifying best practices for engaging them 52 even some scientific disciplines such as project management has considered stakeholder management as one of its core knowledge areas for achieving project success 53 this exponential growth of the field has resulted in more than 55 stakeholder definitions 54 and numerous frameworks for stakeholder identification 355556 categorization 5758 and engagement 59 60 61 62 however the enlargement of the stakeholder analysis body caused ambiguousness in its concepts and purpose 345663 where it turned into an experimental field for different methods to be explored jepsen and eskerod 64 revealed that the tools used for stakeholder identification and categorization were not clear enough for project managers to use being referred to as theoretical 65 the theoretical debates seemed to have alleviated between 2010 and 2020 where researchers focused instead on the applicability of stakeholder theory in the real world cases 6667 empirical studies mainly examined the behavior of firms and their stakeholders towards each other such as how firms manage stakeholders 6869 and how stakeholders influence a firm 70 once again the scientific paradigm of stm has mostly been uncovered in the domains of strategic management 7172 and project management 73 74 75 therefore it is evident that growth of stm has continued on a much larger scale than in the previous years but little is known about the structure of collaboration networks that have contributed to its development and diversification social network theories and measures a social network is a web of relationships connecting different actors together the purpose of analyzing networks in scientific research is to evaluate the performance of certain research actors through the structure and patterns of their relationships as well as to guide research funding and development of science 76 following previous works 5277 sna can be conducted through a variety of metrics such as egodensity at the network level degree betweenness and closeness centrality efficiency and constraint at the actor level and tie strength at the tie level 7879 at the network level density is the most basic network concept which measures the widespread of connectivity throughout the network as a whole 80 in other words it explains the extent of social activity in a network by determining the percentage of ties present 81 on the other hand egonetwork density is used to describe the extent of connectivity in an egos surrounding neighborhood 82 in this study the ego is either an author institution or country a dense network allows the dissemination of information throughout the network 83 and reflects a trustworthy environment for different actors 84 however a dense network is a twoedged sword where it might obstruct the ability of actors to access novel information outside their closely knitted cliques actor level analysis was first pioneered through the bavelasleavitt experiment which involved five groups of undergraduate students each had to communicate using a specific network structure to solve puzzles 8586 it was found that the efficiency of information flow between group members was the highest in the centralized structures leading to the formation of the network centrality concept accordingly freeman 87 identified three measures of centrality which are degree betweenness and closeness degree centrality that denotes the number of relationships a focal node has in the network in other words it is the number of coauthors associated with a given author degree centrality is mostly considered as a measure of immediate influence or the ability of a node to directly affect others 8889 betweenness centrality is the number of shortest paths that pass through a certain node 52 betweenness centrality is a good estimate of power and influence a node can exert on the resource flow between other actors 879091 a node with high betweenness centrality can be considered as an actor that regularly plays a bridging role among other actors in a network on the other hand closeness centrality measures the distance between a node and others in a network and reflects the speed in which information is spread across the entire network 87 an actor with high closeness centrality is considered independent and can easily reach other actors without relying on intermediaries 81 another important actor level theory is burts 92 structural hole theory which highlights the importance of having holes between actors to prevent redundant information otherwise an actor can have redundant relationships by being connected to actors that themselves are connected where maintaining these relationships could be costly and time consuming in which might constrain the performance of network actors burt proposed using efficiency and constraint to represent the presence of structural holes and redundant relationships respectively regarding tie level analysis granovetter 93 introduced the strength of weak ties theory he argued that individuals with weak relationships can obtain information at a faster rate than those with strong relationships this is because individuals who are strongly connected to each other tend to share information most likely within their closely knitted clique than to transfer it to outsiders in contrast krackhardt et al 94 stressed on the importance of strong ties to create a trustworthy environment facilitate change and accelerate task completion additionally hansen 95 showed that strong ties rather than week ties can enhance the delivery of complex information materials and methods data collection this paper used coauthorship information to explore collaborative networks the web of science database was utilized with the search being restricted to journal articles with strings of stakeholder management or stakeholder analysis or stakeholder identification or stakeholder theory or stakeholder engagement or stakeholder influence in their title abstract or keywords these are the most frequently used themes in stakeholder research to describe the concept of stm other types of documents such as conference proceedings and books were excluded the year 1989 was chosen as the outset date of our research because the results of laplume et al 96 and the web of science search showed that the first stakeholderbased scientific article was published in 1989 in order to have a better understanding of the evolution of collaboration networks different datasets were required therefore the overall time period of 32 years was split into three consecutive subperiods that being t 1 19891999 t 2 20002010 and t 3 20112020 the bibliometric data for each phase was extracted independently in plain text format and involved manuscript titles authors names and affiliations journal titles institutional names identification numbers abstracts keywords publication dates etc out of 21173 authors 3115 were duplicates so 19058 authors were sent for further analysis the number of articles extracted was 85 for t 1 885 for t 2 and 5157 for t 3 counting for a total number of 6127 articles data refinement the bibliometric datasets for the three subperiods were imported into bibexcel package program 97 for data preparation and cooccurrence analysis fig 1 summarizes the entire methodological process used for extracting and analyzing the data the first issue encountered was to resolve name authority control problems therefore a standardization process was conducted by removing duplicates moreover it was important to convert upper and lower cases of all records to a standard lowercase format to avoid duplication of records that might impact network structure for some of the records especially that of institutions and countries it has been shown that cooccurrence has occurred between the same institutions and the same countries in this case the names were not brought together but kept apart due to the fact that collaboration has happened between authors of the same institution or between institutions of the same country in other words selfloops were not excluded from our analysis using bibexcel we extracted social network data for each of the authors institutions and countries networks and for each subperiod that involved information about the presence and absence of relationships between the actors then the data was imported into excel and manually scrutinized to correct possible spelling errors social network analysis the matrices were imported into an sna program used by many network scholarsucinet 60 98 to calculate the social network measures for each matrix ucinet is a sna software mainly used for whole network studies which features a large number of network metrics to quantify patterns of relationships centrality measures were calculated for the authors institutions and countries to determine those that are leading collaborative works in their networks however further network measures such as egodensity efficiency constraint and average tie strength were only calculated for the authors to cohesively understand the longitudinal effect of coauthorship networks on research performance egodensity degree centrality betweenness centrality and closeness centrality efficiency and constraint were calculated for each author institution and country and for each subperiod egodensity is number of actual ties not involving the ego divided by the number of possible ties in an ego network ed ¼ p n i j¼1 z ij nðn à 1þ2 where n refers to the number of alters the ego is connected to z ij is the tie strength between actors i and j and ⁄2 refers to hightest possible number of ties degree centrality is the count of contacts a focal node has in a network 99 it is not reasonable to compare a node with a centrality score of 20 in a network of 50 nodes with a node of same centrality score but in a smaller network of 15 nodes therefore in order to understand the extent to which authors are central in a network and compare their centrality across different networks that vary in size freemans 100 normalized measures for degree betweenness and closeness centrality are used normalized degree centrality d i ¼ p j z ij n à 1 where i is the focal node j is any other actor and z ij 1 for an existing tie between i and j normalized betweenness centrality is calculated as the proportional number of times a focal node lies on the shortest path between other actors 101 b i ¼ x z jq ðiþ z jq n à 1 where i is the focal node j and q are any other two actors z jq is the total number of shortest paths from j to q and z jq is the contribution of i to those paths normalized closeness centrality is the total number of distances between the focal node and all other nodes c i ¼ x zðpj pqþ à 1 n à 1 where z is the shortest distance between node pj and node pq in the network efficiency is measured by dividing the number of nonredundant actors divided by network size e i ¼ p 1 à p p iq m jq h i q 6 ¼ i j n where i is the focal node j and q are any other two actors p iq is the tie strength between i and j and m jq is the tie strength between j and q n is the number of alters in the ego network conversely network constraint measures the extent to which an actors time and energy are invested in contacts who are themselves are connected to one another 102 p ij þ x q p iq p qj � � 2 q 6 ¼ i j where i is the ego having a strong tie with j j is another alter having a strong tie with i and q is also an another alter having a strong tie with j mean tie strength is the sum of the strength of all ties of an ego each tie strength ranging from 1 to 4 divided by the number of alters in a network t i ¼ p j s qj n q where j is the ego q is the alter s qj is the tie strength between j and q and nq is the number of alters in an egos network sociograms to construct and visualize the collaboration networks of authors institutions and countries bibliometric data from wos was directly imported into vosviewera specialized software tool that visualizes networks based on scientific publications 103 data analysis to understand the association between social network measures and research performance the extracted social network measures from ucinet were imported into spss with the number of citations and documents published for each author correlation and ttests determined whether a positive or a negative association exists between the explored variables results and discussion descriptive results a total of 6127 articles were obtained from different journals between 1989 and 2020 as seen in table 1 and fig regarding institutional cooccurrence it is evident that t 3 has witnessed the highest number of collaborative institutions than t 2 and t 1 similarly the number of collaborating countries was the highest in t 3 and the lowest in t 1 given that a scientific field might require 45 years to mature 104 the overall results show that the stm field moved from incubation to incremental growth to maturity reflected by the dramatic increase in the number of articles institutions countries and in the number of citations especially in t 3 social network analysis results using sna the 10 most prolific and influential actors for each network in each subperiod were identified authors table 2 shows that bair jd is considered the most prolific author in t 1 with the most direct connections and the largest betweenness centrality and is considered the closest to all other actors in the network bosse gc driskill jm and fottler md are next in line with same centrality scores followed by friedman r jones tm berman sl agle br and sonnenfeld ja fig 3 shows the evolution of collaborative networks of coauthors by subperiod surprisingly it is shown that some of these authors share the same clique especially for bair jd bosse gc and driskill jm but the majority of the authors in table 2 do not belong to a single integral clique this indicates that collaboration is in the form of subnetworks of closely knitted authors each forming their own collaborative clique it is evident that collaboration is still premature with only 156 authors not well connected in the network t 1 is known as the discovery period of stakeholder theory where it first appeared in management journals 32 in t 2 the collaboration network consists of 1957 authors and has become larger and more condensed than in t 1 however it is important to note that table 1 earlier shows that 62 of articles are single and double authored and only 38 are multiauthored this finding can be noted in network b fig 3 with the emergence of more than 1000 single and dyadic authors that have further fragmented the collaboration network as a whole this disintegration of the stakeholder domain is expected because the stakeholder theory has a wide scope of interpretations and the term stakeholder can mean different things to different people 105 with the increase in stakeholder theoretical disputes between the moral justifications 41 and managerial implications of the theory 3866105 numerous solo dyadic and triadic have risen detaching from both the mainstream stakeholder theory research 3435 and the large network cliques 106107 perhaps a reason why most of the prolific actors in t 1 did not make the list in t 2 is because new research areas have emerged such as stakeholder engagement 108109 stakeholder social network analysis 56110 stakeholder involvement in policy decision making 111 and many more larger cliques are observed which some reaching to 16 authors and with the emergence of numerous small to medium size subnetworks for t 2 a totally new set of influential authors have emerged but being less central than those in t 1 with lower degree and closeness centrality scores but with higher betweenness in general this indicates that collaboration endeavors are mainly driven by clique members rather than by highly central actors similarly another study showed that key authors are more likely to form a wellconnected group that collaborates frequently and diversely 112 rather to collaborate solely through central actors among the most influential actors are boitani i and turner w who have the same centrality scores followed by barnett j brown k then freeman re and grant t who have a lower degree centrality but are still considered highly central by occupying a strong brokerage position bloom g berron p robert a and andersson i are less central but still considered highly influential as it can be interpreted from the graphical visualization in fig 3 that the scenario observed in t 3 is very similar to that in t 2 but with a larger network of 16905 authors in particular the number of components has increased to 88 and expanded to include 12 actors in contrast network densitythe percentage of existing ties over the total number of possible tieshas decreased from 18 in t 1 to 008 in t 3 although it seems intuitive that density would increase with new researchers entering the field this did not seem to be the case where density decreased with further fragmentations that reduced the number of connections as the number of nodes increased this finding is supported by a study 18 that found a decrease in network density of author collaboration networks from 0026 in the 1980s to 0003 in the 2000s in the presence of 16905 authors with different research interests it is nearly impossible to connect the majority of the nodes and achieve a high network density the overlay color range in network c fig 3 also shows that the majority of publications have occurred between 2014 and 2018 with few coauthorships noted in the last two years the sna results presented in table 2 show that tugwell p is the most influential author in the network followed by graham id newman pa dawkins js and walker ce who all have higher degree centrality scores than the rest remarkably the findings of betweenness centrality in t 3 show an increase in the importance of the intermediary role as all prominent actors have a higher betweenness centrality score compared to that of t 1 and t 3 the brokerage role is significant in t 3 with the decrease in degree and closeness scores therefore the collaboration network has become more dependent on authors with a brokerage role in t 3 the evolution of the collaboration network across three decades shows that the stm authors do not belong to the same network this observation has also been reported in the network metaanalysis field where collaborating authors belonged to different network clusters 113 therefore the collaboration network can be best described as involving a high number of authors with different research interests that have pursued different research areas by either being a part of a subnetwork of three or more actors or by working alone or in pairs evidence for radical changes in network structures from t 1 to t 3 other than the increase in component sizes and fragmentation have not been demonstrated where this is still considered an important and unexpected finding the findings show that the stakeholder concept is a multidisciplinary theory applied in various research domains such as in health care management 114 115 116 117 118 119 marine policy 120121 agriculture 24122 applied geography 123124 engineering and architecture 23125 marketing 126 127 128 public affairs 25 129 130 131 project management 73 132 133 134 and tourism 135 136 137 in other words the stakeholder concept has been developed mainly by multidisciplinary teams of both experienced and emerging scientists therefore this finding contradicts what has been recently speculated that stm is still at an early stage and that published studies are still limited 138 institutions institutional collaboration enables the sharing of unique resources and improves research visibility and contribution 16 the results show that the first period contained 88 institutions that have participated in stakeholder research surprisingly 8 out of the 10 most collaborative central institutions are from the united states and are health management link indiana university university of iowa kings daughters hospital penn state university washington state university colorado state university and boston university similar to the author collaboration network in t 1 the institutional network shows that the collaboration network doesnt constitute a main component but is disseminated into several small size components this shows that the above institutions are only influential in their own cliques in contrast to t 1 t 2 has witnessed a wider international collaboration where 8 out of the 10 most prolific institutions are from outside the us also being the top 5 institutions and are erasmus university which has the highest degree centrality and being the most influential intermediary with york university university of london university of queensland university of east anglia followed by two us institutionsuniversity of north carolina and harvard university and then autonomous university of barcelona utrecht university and aarhus university this result is interestingly surprising as it challenges previous studies that showed that most published papers in general are from usa uk and canada which also are the most central in collaboration networks 116139 regarding the network structure and contrary to the institutional network in t 1 the result show the emergence of a main component in t 2 that is well connected and highly centralized by constituting a nucleus of all of the above prolific institutions but surrounded by numerous institutions that are isolates however a deeper inspection reveals that an institution can also be considered highly influential without being embedded in the main component such as in the case of autonomous university of barcelona the results for t 3 show university of leeds being the most prominent institution with the highest degree betweenness and closeness centrality followed by the university of toronto university of washington university of calgary university of oxford university of otawa university of oxford university of british colombia university of melbourne university of sydney and harvard university most of these institutions do not belong to the same components and therefore it can be argued that collaboration is led by highly central actors disseminitated across the entire network this has facilitated the connection of detached neighbourhoods as reflected by the increase in density from 0003 in period 2 to 0014 in period 3 this finding is contrary to koseoglu 20 who found that collaboration network density in strategic management research did not increase across 34 years despite the increase in network size for this reason each period is characterised by having a very distinct list of prolific actors that change with the change in network size and structure moreover the number of vertices has dramatically increased from 1201 in period 2 to 12833 in period 3 it can be argued that interesting patterns were observed in the institutional network for t 3 especially with the reduction of isolates the increased density and the enlargement of the main component in t 2 to include other large cliques that reached 31 nodes this finding contradicts previous research in strategic management that showed that large institutional cliques did not emerge with the enlargement of collaboration network 20 the overlay color range in network c in fig 4 shows that the majority of institutions have published between 2014 and 2018 with a continual rise in 2019 and 2020 countries table 4 provides interesting observations where usa and england are the most prolific actors that are leading collaborative research in the last 32 years this finding is also supported by previous studies that showed that countries in north and south america with europe are the bestconnected countries to faciliate international research collaboration 20 139 140 141 the collaboration network in t 1 only exists because of the brokerage roles performed by usa and england usa stands out by having the most direct relationships brokerage position and being the closest to all other actors usa and england are considered cutpoints that if removed would disconnect the entire two networks for this reason the rest of the countries are considered prolific only because of their only single relationship with either usa or england a number of isolates are also noted and are wales israel belgium sweden spain and new zealand unlike the scenario in t 1 a significant involvement of new countries in the collaboration network is observed in t 2 while still having usa and england as the most central actors an interesting finding is that the majority of countries that followed usa and england were not among the prolific actors in t 1 such as germany italy belgium spain and denmark on other hand some countries that existed in t 1 such as australia cananda and netherlands have taken a more significant role in the collaboration network in t 2 while scotland hungary thailand jamaica and ireland have dissappeared from the prolific radar for t 2 and t 3 remarkable the network density of the country contribution network in t 2 and t 3 are 112 and 10 which are considered the highest compared to all of the previous networks in most decades fig 5 shows that the collaboration network of countries started by being uncondensed fragmented and highly centralised with 16 countries controlling the marjority of connections to a highly dense less fragmented network of 74 countries in t 2 to a larger network of 141 countries and 1059 vertices counting for a 10 density in t 3 network 3 fig 5 shows that the majority of countries emerged between 2014 and 2017 to our knowledge a well connected network of collaborative countries as observed in t 2 and t 3 is not occasional geographic linguistic and cultural distances between scientists of different countries may significantly impact collaboration prevalence 142143 according to li et al it is more often for collaboration to occur within the same country or same institution due to many reasons including the ease of communication low intracompetition and low funding opportunities for example a study on how higher educations perceive stakeholder salience was possible due to the collaboration of benneworth and jongbloed 144 who both were researchers at the university of twente in the netherlands however the findings in this study allowed us to observe cross country collaboration since the origin of stakeholder theory in the 1980s perhaps a contributing reason for this global collaboration at least in part is the presence of several funding agencies such as the economic and social research council that supported many stakeholder research studies which brought together many scientist from different countries such as wales england spain and sweden 145146 effect of coauthorship networks on research productivity and citationbased performance a preliminary investigation of the associations involved exploring the correlations between actors network attributes and research performance for each period since the assumption of normality has been violated nonparametric tests of spearman correlation and mannwhitney u test were conducted the results in table 5 show that the correlations varied differently across the three subperiods with regards to magnitude direction and significance research productivity is shown to have the strongest correlation with tie strength in t 1 betweeness centrality in t 2 and egodensity in t 3 on the other hand citation counts is mostly correlated with tie strength in t 1 and t 2 remarkably the correlations between research productivity and each of degree centrality and tie strength in t 3 have shifted its direction as opposed to the positive correlations in t 1 and t 2 the results overall show that all social network variables are either negatively or positively correlated with research performance to explore the association between egodensity and research performance the median for egodensity index was chosen as a cut point to segregate the participants into two groups authors with egodensity scores above the median and are considered as high egodensity group and authors with egodensity scores lower than the median and are considered as low egodensity group the results of the mannwhitney u test summarized in table 6 show a positive association in t 1 with higher research performance scores observed in the highdensity group than the low density group similarly the results show a positive association in t 2 with higher research performance scores observed in the high density group than the low density group accordingly we argue that it was essential to have highly dense collaborative clusters in the first decade to publish scientific papers that can bring awareness to stakeholder theory as a newly developed theory of management and ethics the results show that degree centrality is positively associated with both research productivity andcitation counts in t 2 while no association in t 1 in particular authors with numerous collaborative relationships in t 2 had higher citation counts and research productivity than those with fewer relationships u 411370 p 000 and u 449944 p 003 respectively in t 3 a positive association is shown between degree centrality and citation counts where regarding betweenness centrality and research performance the results show that authors that lie on the shortest path between other authors had better research performance in t 2 in terms of research productivity u 1704 p 000 and citation counts u 20655 p 000 than those who are not considered intermediaries similar results are shown in t 3 between the low betweenness group in terms of research productivity u 119157 p 000 and citation counts u 586781 p 000 and the high betweenness group the absence of a positive association in t 1 can be explained by the low number of authors that disabled the formation of large cliques in which its structures prompt brokerage salience with respect to closeness centrality the overall results show a positive association in all periods where authors with low closeness centrality in t 1 had lower research productivity that those with high closeness centrality u 2658 p 004 in t 2 the results show that authors with low closeness centrality had low research productivity and citation counts than those with high closeness centrality and high closeness group u 2572243 p 000 the only exception is in t 2 with research productivity where a negative association is observed where low closeness group having higher research productivity than the low closeness group u 3058094 p 037 hence the findings infer that the closeness of authors to each other was important for all periods in enhancing research performance except for research productivity in t 3 which relied more on authors with high degree and betweenness centrality as shown by the above results efficiency is positively associated with research productivity and citation counts for all periods for t 1 authors who were surrounded by nonredundant ties had higher citation counts and research productivity than those who have a less efficient network position u 1977 p 000 for citation counts u 2742 p 005 for research productivity similarly authors who were surrounded by nonredundant ties had higher citation counts and research productivity than those who have a less efficient network position u 429965 p 000 for citation counts u 472013 p 001 for research productivity similarly efficient authors had higher citation counts and research productivity than those who were less efficient u 2848639 p 000 for citation counts u 2414066 p 005 for research productivity these findings indicate that authors surrounded by structural holesbeing connected to a primary coauthor in a group and receiving novel informationhad good research performance moreover it can be argued that expansion of the stm field relied on novel information flowing between efficient authors of different disciplines the findings show that constraint is positively associated with research performance in t 1 and t 2 while in t 3 a negative association is shown instead in particular authors with redundant ties had higher research productivity in t 1 and citation counts in t 2 than those that are less constrained this finding contradicts previous research which showed that constraint is negatively associated with research performance before year 2010 147 however in t 3 a negative association is shown were highly contrained individuals had lower citation counts than those that are less constrained u 25726787 p 000 therefore research productivity in t 2 and citation counts in t 3 have been mainly enhanced via authors with redundant relationships that lead back to same group of coauthors we argue that with the wide expansion of the collaboration network in t 3 that had witnessed the emergence of many scholars it is difficult for authors to establish relationships with all members of a clique and therefore must rely on relationships established with primary actors reflected by the salience of structural holes with respect to tie strength the findings show a positive association with research performance in t 1 and t 2 with regards to t 1 the results show that authors who had strong relationships with other authors had better citations and research productivity than those with weaker ties similarly in t 2 authors with strong ties had higher citations and research productivity than those with weak ties therefore the theory of strong ties 94 in ehancing productivity is supported by our analysis strong relationships between coauthors are essential for increasing citation and publication counts conclusion and implications this study descriptively analyzed the evolution of research collaboration networks of authors institutions and countries in the stm discipline and identified key actors that are leading collaborative works in addition this study examined the longitudinal effect of coauthorship networks on research performance by exploring the associations between collaborative social network variables and each of citation counts and research productivity the findings of the authors collaboration network revealed a premature and fragmented network in t 1 where collaboration has happened in the form of subnetworks or cliques of closely knitted actors in t 2 the network increased in size by the emergence of mostly single and dyadic authors which further disintegrated the network in t 3 a larger network and a higher number of cliques emerged with the most prolific actors having a strong brokerage role the overall results show that stakeholder theory has a wide scope of interpretations and lacks universal consensus on its concepts and frameworks 3435148149 the findings of the institutional collaboration networks revealed that the collaboration network in t 1 is fragmented into several small size cliques controlled mostly by us institutions in contrast a wider international collaboration was witnessed in t 2 with the emergence of non usinstitutions the results for t 3 showed that the most prolific universities did not belong to the same components therefore indicating that the collaboration is led by highly central actors disseminated across the entire network the collaboration network of countries originated by being uncondensed fragmented and highly centralised in t 1 with only 16 countries where usa and england being the most prolific actors in stm research the collaboration network became highly dense and less fragmented in t 2 with 74 countries joining the scene a larger network of 141 countries was observed in t 3 with high density and less fragmentation regarding the impact of coauthorship networks on research performance efficiency was found to be the only network measure positively associated with both citation counts and research productivity in all of the three periods indicating the importance of structural holes in enhancing research performance in summary stm research performance is influenced by authors in highly dense collaborative clusters are close to all other actors in the network efficient constrained by repetitive relationships and that have strong ties with other authors this paper contributes to stm reseach by showing the evolvement of the field and the dynamic changes in its structures the findings demonstrate that stm is indeed a multidisciplinary discipline reflected by fragmented coauthorship network from t 1 to t 3 and the emergence of a high number of single and dyadic author representing disunity in stm research interest this heeds the growing calls to explore the structural composition of stm 150 fig 6 supports this notion which illustrates keyword cooccurrence networks in stm discipline in t 1 t 2 t 3 the main keywords with the highest cooccurrence in t 1 are stakeholder analysis stakeholder and stakeholder theory which all were fundamental and related concepts in stm but each belonging to a different clique this indicates that stm had not received profound universal consensus at that time and had various comprehensions however the application of stm in other disciplines was on the rise especially with stakeholder analysis coinciding with strategic planning climate change and participatory research in t 2 new major keywords appeared such as corporate social responsibility business ethics and corporate governance all belonging to the same cluster indicating wide acceptance of stakeholder theory as a theory of management and ethics other nonrelated stm keywords had also emerged indicating that stm is a living wiki that is continuously growing through the collaboration of stakeholder scholars from different research fields 32 this study provides practical contributions to scientists in the stm field and educational managements worldwide first the concrete findings from the association testing can help stakeholder scientists improve their research performance by altering the configuration of their collaborative relationships especially degree betweenness and closeness centralities institutions can benefit from these results to increase citations rates and research productivity second this study provides empirical evidence regarding the structure of collaboration networks and central actors that if acted upon can directly or indirectly lead the allocation of government funding maximization of research outputs improvement of research community reputation and the enhancement of cost savings 2930 that can all improve collaboration and developing coordinated research programs that can advance the field all relevant data are within the paper and its supporting information files supporting information s1 file methodology julian fares supervision kon shing kenneth chung visualization julian fares writing original draft julian fares writing review editing julian fares kon shing kenneth chung alireza abbasi

this paper explores the evolution of research collaboration networks in the stakeholder theory and management stm discipline and identifies the longitudinal effect of coauthorship networks on research performance ie research productivity and citation counts research articles totaling 6127 records from 1989 to 2020 were harvested from the web of science database and transformed into bibliometric data using bibexcel followed by applying social network analysis to compare and analyze scientific collaboration networks at the author institution and country levels this work maps the structure of these networks across three consecutive subperiods t 1 19891999 t 2 20002010 t 3 20112020 and explores the association between authors social network properties and their research performance the results show that authors collaboration network was fragmented all through the periods however with an increase in the number and size of cliques similar results were observed in the institutional collaboration network but with less fragmentation between institutions reflected by the increase in network density as time passed the international collaboration had evolved from an uncondensed fragmented and highly centralized network to a highly dense and less fragmented network in t 3 moreover a positive association was reported between authors research performance and centrality and structural hole measures in t 3 as opposed to egodensity constraint and tie strength in t 1 the findings can be used by policy makers to improve collaboration and develop research programs that can enhance several scientific fields central authors identified in the networks are better positioned to receive government funding maximize research outputs and improve research community reputation viewed from a networks perspective scientists can understand how collaborative relationships influence research performance and consider where to invest their decision and choices

introduction even before the covid19 pandemic anxiety disorders were the leading causes of burden globally despite the existence of intervention strategies aimed at reducing their effects the covid19 pandemic has had a significant impact on public health including mental and physical health moreover anxiety has been reported as a common experience among covid19 patients while the publics pandemicrelated health concerns and fears of contracting covid19 serve as contributing factors to anxiety a largescale metaanalysis of 71 published papers revealed there was a 326 total prevalence of anxiety during the covid19 pandemic while the prevalence estimates of anxiety differ remarkably across countries and populations meanwhile people with mental health disorders may be considerably more affected by emotional reactions in the form of anxiety generated by the covid19 pandemic many studies have suggested that anxiety during the covid19 pandemic is associated with certain sociodemographic characteristics healthrelated factors and sociopsychological factors available research indicates that females and those of a younger age who lived in rural areas and had lower socioeconomic status had a higher risk of anxiety moreover other social and economic factors such as economical struggles unemployment being unmarried having chronic diseases sedentary behavior and poor sleep quality were associated with anxiety during the covid19 pandemic the literature has also suggested that the covid19 pandemic has triggered feelings of fear as a response to the sense of extreme threat for both the community and individuals moreover metacognitions intolerance of uncertainty and emotional dysregulation have all been linked to the fear of covid19 and anxiety changes in daily life loneliness social isolation have had a huge impact worldwide with serious psychological implications loneliness can occur not only in the context of social isolation but can even be felt when others are physically present and has been linked to anxiety implying that lonely persons are more vulnerable meanwhile the prolonged stayathome and confinement conditions have led individuals to be more engaged with technology use the internet as a valuable source of health information has become more widely used by the general population during the ongoing covid19 pandemic however repeated media exposure to pandemicrelated material and extensive online searches for healthrelated information can intensify anxiety and develop a cycle of psychological discomfort that is hard to break in addition problemsolving is a broad coping technique that promotes and sustains general competence and adaptability it can have positive andor negative orientations while the deficits of positivelyorientated problemsolving show significant correlations with anxiety finally resilience is a dynamic process that involves adaptation in the face of adversity and refers to the tendency to retain stable healthy functioning following a potentially stressful life experience recent data suggest that during the covid19 pandemic highly resilient risktolerant individuals reported having lower anxiety there are concerns that covid19 pandemic could lead to increased suicide rates however the data concerning suicidality during the covid19 pandemic are not conclusive the risk of suicide may have increased due to the stigmatization of covid19infected patients and their families moreover people with psychiatric illnesses may experience worsening symptoms or develop altered mental states which is related to increased suicide risk high levels of suicidality have been reported previously while the data on suicides from 21 countries have shown no evidence of a significant increase in suicide risk since the pandemic began conversely other studies have suggested that that the covid19 pandemic may trigger suicidality and behavior for example fountoulakis et al assume that stress and anxiety develop first followed by depression and suicidality following the world health organizations declaration of a global pandemic the latvian authorities declared the first state of emergency in march 2020 with a number of epidemiological security measures and restrictions primarily the restriction of meetings travel most public places and educational institutions which lasted until june 2020 noteworthy at that time restrictions due to the pandemic in latvia were much milder than in other baltic and european countries according to the latvian national health service data as of 1 july 2020 there were 1118 confirmed covid19 cases in latvia with 32 deaths and 198508 tests having been performed a strict lockdown due to large increase in covid19 cases was first introduced in october 2021 given that the covid19 pandemic is a global problem that has affected countries to varying degrees there is a need for a transnational understanding of the potential sociodemographic and sociopsychological predictors of anxiety this need is reinforced by the fact that latvia before the pandemic had one of the highest suicide rates in europe moreover anxiety in the general latvian population has not yet been estimated in addition to determine the anxiety status of the general population during the covid19 pandemic key risk and protective factors need to be identified to determine an atrisk group and measures that can be taken to protect those who are at risk from anxiety symptoms and improve their mental health this study aims to investigate the association between sociodemographic healthrelated and sociopsychological determinants and anxiety and identify the predicting factors for anxiety in the general population of latvia during the state of emergency from march to june 2020 methods the survey we conducted a quantitative crosssectional online survey that included a randomized stratified sample of the latvian general population aged 1874 years the survey was within the framework of the national research program and a sample of the latvian general population was a part of the covid19 mental health international for the general population project cometg is large international study with sample of 55589 participants from 40 countries who filled the structured questionnaire the survey was translated from english into latvian and russian both translations were then studied by a latvianand russianspeaking focus group for verification the cometg study protocol was supplemented with sections of the questions on the sociopsychological impact of the covid19 pandemic and the attitude on the measures implemented by the government the full survey consisted of 27 thematic sections including questions on sociodemographic information overall mental functioning general health status fear of covid19 thoughts on the preventative measures taken against covid19 family relationships lifestyle changes spiritual inquiries internet use psychological resilience emotion regulation positive and negative orientation toward social problems and loneliness the detailed protocol of the cometg is available in the web appendix at fountoulakis et al data collection the data collection was conducted from july 6 to 27 2020 the fieldwork team that was provided by the research company kantar followed the esomar international code on market and social research the data collection was stratified by gender age region urbanization and nationality and was based on statistics published by the office of citizenship and migration affairs of latvia a precisely selected and segmented database was used to correspond to the general population of latvia thus ensuring the representativeness of the sample of respondents an ssl data transmission protocol was used to ensure the security of the online data transmission respondents received individual invitations by email with a password and a link to an online questionnaire which could be completed by respondents at their preferred time until the specified survey closing time july 27 a reminder about completing the questionnaire was sent to participants by email during the fieldwork the database was regularly cleaned inactive participants were deleted and the database was continuously updated with new participants when the respondent filled out the questionnaire it was saved on kantars server and was not available for later editing each survey item was assigned an id code and the data were collected anonymously online the study was approved by the ethics committee of riga stradins university riga latvia the first page of the online questionnaire included the declaration of voluntarily consent for participation measures anxiety anxiety symptoms were measured using the statetrait anxiety inventory which was part of the online questionnaire the internal consistency of the stai in our study was good the cutoff point for the stais scores used in our study was based on the normative data information the cutoff score was computed as follows c s 0 m 1 s 1 m 0 s 0 s 1 where m1 mean of the clinical group s1 standard deviation of the clinical group m0 mean of the nonclinical group and s0 standard deviation of the nonclinical group according to the equation a cutoff score of 36 was determined the participants changes in anxiety were assessed using selfrated responses to the question how much has your emotional state changed in relation to the appearance of anxiety and insecurity compared to before the covid19 pandemic the responses were scored on a fivepoint scale sociodemographic determinants to verify the association between anxiety and the sociodemographic characteristics the participants gender age ethnicity urbanization family status education and employment were recorded being a close relative or caretaker of a person who is at high risk of becoming infected with covid19 was assessed by yes or no responses healthrelated determinants the participants general health was assessed by the question in general how do you rate your health over the last month the responses were answered on a fivepoint scale there was also an additional question do you suffer from any chronic medical somatic conditions selfreported mental disorders in the past were acquired by the question in the past have you had any mental health problem that were serious enough to make you seek professional help psychotherapy or medication treatment the responses were in the form of yes or no suicidality and behaviors we used the risk assessment of suicidality scale to assess participants suicidality and behaviors the rass was previously validated in a study using a general greek population sample and was found to be a reliable tool the internal consistency of the rass in our general latvian population sample was found to be good sociopsychological determinants we assessed fear of covid19 relationship quality religiousspiritual inquiries internet use and daily routine using the questions that are available on the cometgs web appendix psychological determinants we evaluated loneliness using the statement i felt lonely more often during the state of emergency situation than in the situation before the responses were scored on a fourpoint scale we used the emotion regulation skills questionnaire which was previously adapted for use in latvia to evaluate participants emotional regulation ability the ersq consists of 27 statements divided into 9 scales with responses scored on a fivepoint scale however this study only used the total score we used the psychological resilience scale which is a sevenitem measure to assess participants psychological resilience the responses were scored on a fivepoint scale finally we used the social problemsolving inventoryrevised version which was previously adapted for use in latvia and is a multidimensional measure containing 52 statements this study used two shortform scales the negative problem orientation and the positive problem orientation the responses were scored on a fivepoint scale statistical analysis descriptive statistics were computed for all variables used in the analyses a cutoff point of the stais score was used to determine anxiety we conducted betweengroup comparisons of frequencies using pearsons chisquare test for categorical variables and the post hoc analysis involved pairwise comparisons using the multiple ztest of two proportions with a bonferroni correction an independent samples ttest was used to analyze the mean differences for the continuous variables between anxiety and nonanxiety group variables that achieved a screening level of significance were simultaneously entered into a binomial logistic regression data were analyzed with spss version 270 results sociodemographic determinants and their association with anxiety of the 3110 questionnaires received after data cleaning and weighing 2608 questionnaires were obtained the mean stais score of the total sample is 2288 ± 1225 in the total sample 152 are classified as having anxiety table 1 presents the samples sociodemographic characteristics and a chisquare test results all expected cell frequencies were greater than five the prevalence of anxiety among females is much higher than among males the comparison by age group reveals that the proportion of 1829yearolds is significantly higher in the anxiety group compared to the nonanxiety group and lower in the age group containing 4049yearolds the anxiety group has a difference in the proportion of latvians and russians when compared to the nonanxiety group the proportion of people living in the rural area is lower in the anxiety group compared to the nonanxiety group meanwhile those who are caretakers or close relatives of a person in a vulnerable group are more likely to meet the criteria of having anxiety compared to participants who are not the results are statistically significant there was not a statistically significant association between anxiety and such sociodemographic variables as family status χ 2 284 p 0416 education χ 2 289 p 0235 and employment χ 2 368 p 0298 healthrelated determinants of anxiety all healthrelated variables analyzed in this study were statistically significantly associated with anxiety results of chisquare test show that of those who had anxiety 613 show that their emotional state has worsened a little compared to 230 of those without anxiety and 173 show that it got a lot worse compared to 09 of the group without anxiety a total of 131 of respondents with anxiety state that their anxiety is neither better nor worse compared to 714 of participants without symptoms of anxiety a total of 359 of respondents with anxiety report a moderate or bad general health status compared to 112 of respondents without any health conditions a total of 347 of those with anxiety suffer from chronic somatic conditions compared to 271 of respondents without anxiety the participants with anxiety also have had significantly more mental health disorders in the past table 3 shows that 209 of the participants who have anxiety confirm that they have a fear of dying 26 have frequent thoughts of harming themselves and 36 have suicide ideation participants with anxiety show an increased tendency to think about suicide compared to those without anxiety a total of 11 of participants with anxiety indicated at least one attempted suicide in the past compared to 48 of participants without anxiety sociopsychological determinants of anxiety table 4 shows that moderate and severe fears of contracting covid19 are statistically significantly more prevalent in participants with anxiety than those without anxiety as well as the fear that a family member could contract covid19 and die meanwhile fear of possible stigmatization are statistically significantly associated with those with anxiety than those without anxiety the belief that the covid19 precautions are effective is not associated with symptoms of anxiety table 5 shows that moderate to severe worries about covid19 information on the internet are statistically significantly more prevalent in respondents with anxiety than those without anxiety participants with anxiety are more prone to using the internet moderately to more than usual than the participants without anxiety increased use of social media is also associated with the tendency to meet the criteria of anxiety the results show statistical significance table 6 shows that increased conflicts with family members worsening of the overall quality of relationships with the family members difficulties in maintaining a basic daily routine financial difficulties due to the pandemic and feelings of loneliness show statistically significant association with anxiety weak to moderate association with the stais score participants with anxiety show significantly lower results for psychological resilience emotional regulation skills and positive problem orientation but higher mean scores for negative problem orientation psychological determinants of anxiety factors that predict anxiety a binomial logistic regression was performed to ascertain the effects of sociodemographic healthrelated lifestyle and psychological variables on the likelihood that participants have anxiety twentyeight factors which were found to be associated with anxiety at a pvalue of 005 were further analyzed using the multiple logistic regression model to determine the predictors of anxiety linearity of the continuous variables with respect to the logit of the dependent variable was assessed via the boxtidwell procedure a bonferroni correction was applied using all 50 terms in the model resulting in statistical significance being accepted when p 0001 based on this assessment all continuous independent variables were found to be linearly related to the logit of the dependent variable there was 66 standardized residuals with a value of 1082 to 711 standard deviations which all were kept in the analysis because they form only 253 of protective factors found to be improvements in general health status maintaining ones daily routine having a stable economic situation and having good psychological resilience discussion this study investigates the association between anxiety and sociodemographic and healthrelated characteristics as well as psychological determinants to predict the factors for anxiety using a representative sample of general latvian population during the covid19 state of emergency the study sample included 2608 participants it is noteworthy that the prevalence of anxiety in the general latvian population has not yet been estimated although there is currently an ongoing population study on the prevalence of mental disorders and suicidality in latvia the current study found that the prevalence of anxiety was estimated at 152 which is in line with the average prevalence of anxiety disorders in europe many studies have suggested that covid19 has triggered higher levels of anxiety and distress than the estimated anxiety prevalence rate found in our study however it is important to mention that different methodologies and tools have been used across these studies and high level of anxiety might also depend on the temporal situation and specific events another important aspect is that individuals who have been isolated and quarantined due to covid19 have experienced significant levels of anxiety anger confusion and fear moreover at the time of our study restrictions related to the pandemic in latvia were much milder than in other baltic and european countries the data analysis revealed that anxiety was 244 times more prevalent in females than males this finding is in accordance with most of the data received from different countries and indicates that females are at a higher risk of anxiety disorders although anxiety was more prevalent in the youngest age group age was not significant in the logistic regression model unsurprisingly the data indicate that people with preexisting mental health disorders show higher levels of covid19related anxiety than those with no history of mental health disorders our study confirmed this finding as those who had mental health issues in the past were 145 times more likely to have anxiety while some studies have also indicated that individuals with chronic medical conditions are more likely to have anxiety our study found that the presence of a chronic somatic disorder was not a significant predictor it is noteworthy that we found that the presence of chronic somatic disorders in the general latvian population was not a risk factor for depression during the state of emergency from march to june 2020 moreover in the study on the 12month prevalence of major depression in latvia was found that presence of three or more selfreported somatic conditions is related to increased odds of major depression while presence of one or two somatic disorders is not moreover in our study selfrated better general health was related to decreased odds of having anxiety and served as a protective factor the previous literature has addressed that before the pandemic acute stress was related to suicide ideation in older adults who had severe medical conditions moreover the high risk of suicide during the pandemic has been associated with high levels of perceived stress depression and insomnia our study found that during the state of emergency the fear of dying thoughts of harming ones self and suicide ideation were more prevalent in those who had anxiety the logistic regression analysis revealed that fear of dying during the state of emergency and suicidality in the past increased the odds of having anxiety and therefore were significant predictors of anxiety but selfharm behavior in the past was not a significant predictor fountoulakis et al developed a model to explain the effect of the pandemic on mental health that is based on the assumption that anxiety develops first and then progresses into depression and then suicidality fears about the covid19 pandemic ones health status family members and stigmatization were significantly more prevalent in those who had anxiety and served as predictors to anxiety the data from previous studies have suggested that the covid19 pandemic has contributed to existential fears of infection and death moreover the existing research has highlighted the important role of the complex relationship between fear stress and anxiety in the development of depression in our study a decline in the overall quality of family relationships and increased family conflicts were more prevalent in the participants who had higher anxiety scores anxiety was also more prevalent among those who had difficulty in maintaining a basic daily routine maintaining a healthy lifestyle to help foster selfefficacy can therefore be presented as a protective factor for anxiety the logistic regression model revealed two important factors that played a protective role against anxiety maintaining a daily routine and having financial stability these findings are in line with the existing research the previous studies have indicated a rise in problematic internet use and overuse by the general population during the pandemic disordered internet use generates marked distress worry and significant impairment in personal family social educational and occupational functioning moreover internet browsing about covid19 distress related to this gender is for females compared to males b2 chronic medical somatic condition is for yes response compared to no b4 caretaker of person from vulnerable group is for yes response compared to no b5 mental health problems in the past are for yes response compared to no odds ratio exp information excessive time spent on the internet and increased use of social media have been associated with increased anxiety in the general population during the pandemic although we found that excessive time spent online and more frequent social media use during the state of emergency was more prevalent among those who had anxiety the logistic regression analysis revealed that these factors were not significant predictors of anxiety in our study excessive worrying about covid19 was a significant risk factor for having anxiety yet a change in social media use was not a risk factor which is in line with a study on interactions between anxiety levels and life habits changes in the general population of russia we also found that an increase in internet usage was not a significant predictor loneliness has been identified as a major adverse consequence of the covid19 pandemic the previous studies have reported that when people are isolated or lonely they become significantly more vulnerable to anxiety in our study those who had experienced loneliness were 190 times more likely to risk having anxiety this result indicates that anxiety can be predicted when people have low psychological resilience our results support the recent studies during the covid19 pandemic that show that having a lower psychological resilience score indicates a higher level of anxiety our data also show that anxiety can be predicted by having a negative orientation in problemsolving during the pandemic a major strength of our study is that it includes a large representative sample of the general latvian population which allows for both estimations and determinants of anxiety at the national level our results also highlight the importance of supporting those who are at risk to alleviate suffering in the instance of future possible lockdowns and emphasize that groups that already had poor mental health before the pandemic are at risk both during and after the pandemic these findings show the importance of providing the community with the necessary psychological support to reduce anxiety in addition to focusing on the negative effects it is very important to develop prevention and intervention measures that aim at thriving so as to reduce harm and achieve positive results this study has several practical implications our findings can help develop future strategies for managing psychological support for segments of the population who are at risk our results indicate that the following measures could be implemented improve the recognition of anxiety and other mental disorders at the primarycare level and provide general practitioners with advice and consultations from mental health specialists use a variety of communication channels to inform the target group about simple realistic effective and evidencebased selfhelp strategies for mental health prevention and promote and strengthen psychological resilience techniques and enable collaboration between psychiatrists psychologists and policymakers to develop effective interventions and implementation strategies to strengthen the psychological resilience of the latvian population conclusion this study examines the association between various factors and anxiety and identifies the predicting factors for anxiety using a representative sample of the general latvian population during the covid19 pandemic we identified the following predictors for anxiety being female having mental health problems in the past suicidality having fears about ones health status due to covid19 fear of stigmatization if infected with covid19 worrying about information on the internet loneliness and having negative problem orientation protective factors were also identified these findings confirm previous recommendations by other authors on the need for proactive intervention to protect the mental health of the population but especially of vulnerable groups limitations the results of current paper must be considered in the context of some limitations our crosssectional study did not allow us to make any causal interferences therefore further longitudinal studies could provide more information on causal relationships an important limitation is that invitations were sent to potential respondents via email for that reason certain groups of the latvian populations probably were less likely to fill in the questionnaire another important limitation that may have influenced the results is the use of selfreport measures and scales for example anxiety symptoms were measured using a selfreported questionnaire which may have brought bias to an overestimation or underestimation of the prevalence of observed pathology moreover there is no clinical verification of anxiety disorders finally recall bias may have influenced some measures such as report of existing chronic somatic disorders it should be noted that latvian population speak latvian or russian and the preparation phase of the study was limited in time therefore it was not possible to validate the measures used in the cometg study voluntary recruitment can also lead to socalled nonresponse bias where nonrespondents may have different characteristics than survey respondents in the present study it was impossible to identify whether the nonparticipants were significantly different from the sample of the survey respondents and this is one major limitation of our study it is noteworthy to mention that as a part of the study was international the use of a single protocol was critical it is also important to state that the data were collected in july 2020 in the period when number of covid19 cases in latvia was low moreover during the state of emergency from march to june 2020 the covid19 restrictions were noticeably milder than in other baltic and european countries finally use of highly related variables in logistic models may affect significance it would be worthwhile to conduct a similar study in the future to investigate the longterm outcome and the longterm impact of the pandemics on mentalhealth of the latvian population because of more strict covid19 restrictions and significantly increased rates of the cases of infected people and the death rate finally the lack of baseline data concerning anxiety and related factors before the pandemic did not allow us to make any comparisons responsible for the translation of the developed questionnaire into russian and participated in writing the manuscript ik participated in writing the manuscript ds coordinator of the cometg project kf principal investigator of the cometg project and development of the study protocol er contributed with development of the conception and design of the study is a national coordinator of the cometg project and participated in writing the manuscript all authors participated in interpreting the data and developing further stages and the final version of the paper data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by ethics committee of research in riga stradins university the first page of the online questionnaire included the declaration of voluntarily consent for participation 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

background the covid19 pandemic and its restrictive public health measures have seriously affected mental health of society social psychological and healthrelated factors have been linked to anxiety in the general populationwe investigate the association of various sociopsychological and healthrelated determinants of anxiety and identify the predicting factors for anxiety in the general population during the covid19 state of emergency from in latviawe conducted an online survey using a randomized stratified sample of the general adult population in july 2020 for 3 weeks anxiety symptoms were measured using the statetrait anxiety inventory stais sociodemographic healthrelated sociopsychological characteristics and suicidality were identified using the structured questionnaire the statistical analysis included pearsons chisquare test post hoc analysis and binomial logistic regressionthe weighted study sample included 2608 participants the mean stays score of the total sample was 2288 ± 1225 in the total sample 152 n 398 of participants were classified as having anxiety the odds ratio or of having anxiety was higher in females or 244 95 ci 175333 and people who had experienced mental health problems in the past or 145 95 ci 103204 had suicide attempt in the past or 168 95 ci 108259 were worried about their health status due to covid19 or 164 95 ci 136116 were worried about stigmatization from others if infected with covid19 or 118 95 ci 103135 were worried about information regarding covid19 from the internet or 124 95 ci 108143 persons who were lonely or 190 95 ci 154234 and persons with negative problem orientation or 126 95 ci 106151 protective factors were identified as having good selfrated general health or 068 95 ci 058081 maintaining a daily routine or 074 95 ci 061090 having financial stability or 066 95 ci 055079 and having good psychological resilience or 090 95 ci 087094 vrublevska et alconclusions this is the first study to report a prevalence of anxiety in the general population of latvia certain factors that predict anxiety as well as protective factors were identified

introduction the covid19 pandemic brought on a mass social experimentation of a working from home arrangement and produced a tremendous amount of new information about wfh which altered ones perceptions about its practicality and effectiveness 1 the wfh arrangement induced by the pandemic also demonstrated the feasibility of continuing wfh for many workers in different jobs across many industries beyond the pandemic 2 correspondingly there is a sudden growth in the literature on various aspects of a wfh arrangement induced by the pandemic and its future implementation building up a rich body of knowledge these include its challenges and opportunities its impacts on personal and organizational performance and the implications of wfh after the pandemic in contrast to the vast literature on wfh in prepandemic times authors have stressed that care should be exercised in drawing the lessons learned about wfh based on this pandemic period 27 this is because the uncertainties and unusual caregiving arrangements had placed greater stress on workers 8 9 10 nonetheless this body of knowledge will continue to grow as the pandemic has catalyzed the shift to wfh and there is strong evidence that wfh especially under a hybrid mode has been seen as a new normal after the pandemic 1311 this study aims to contribute to this body of knowledge given that little empirical work exists on the wfh mandate experiences of the construction workforce during the pandemic although a considerable portion of the literature is devoted to the impacts of the pandemic on the construction industries across many countries most studies had considered construction site operations particularly onsite construction workers health and safety issues as revealed in the respective systematic review studies using a gender lens this study explores the female workforce perceptions of the wfh mandate arrangement induced by the pandemic in the context of the australian construction industry the specific objectives are to explore the respondents wfh experiences prior to and during the pandemic examine how they perceived the impacts of challenges associated with wfh on their work activities and performance and explore the relationships among critical challenges associated with wfh the respondents demographic characteristics and their overall satisfaction with wfh and preference for wfh after covid the findings provide useful insights for employment organizations and have implications for their attempts to reoptimize their current wfh practices this exploratory study also lays the groundwork for further research efforts on wfh practices in the industry working from home before and during the covid19 pandemic while a spotlight was thrown on the wfh arrangement following its sudden growth due to the covid19 pandemic it is not a new or novel workplace practice wfh has been well covered in the literature during the prepandemic periods theoutcome of the vast literature is a collection of systematic review studies focusing on wfh from various perspectives including its benefits and drawbacks 15 the relationships between flexible working and individual and organizational performance outcomes 16 and the psychological mediators and individual consequences of telework 17 however the prevalence of remote working was considerably low as revealed in the literature for example in the uk felstead and reuschke 18 found that the shift to wfh had been gradual with a 3 increase over almost 40 years between 1981 and 2019 topped at 47 in 2019 just before the pandemic similarly in the european union 54 of employed persons aged 15 to 64 usually worked from home in 2019 and this trend was consistent throughout the last decade 19 on the other hand mokhtarian et al 20 opined that the prevalence rates of telecommuting vary greatly in the literature due to the different telecommuting arrangements the different samples and sampling techniques across studies nonetheless with the focus mainly on voluntary andor informal wfh mode previous studies in prepandemic times provide suggestive evidence on its benefits both at personal and organizational levels 71517 following the onset of the covid19 pandemic in 2020 a radical shift to a wfh arrangement was mandated due to lockdowns imposed by governments and affecting millions of workers across the globe the resulting large and enduring uptake of whf is associated with major operational challenges for organizations which scrambled to adapt to a near instantaneous change in managerial and personnel work practices 1 correspondingly there is a surge in studies related to mandatory wfh in different contexts and perspectives creating a vast body of knowledge with mixed results and outcomes authors stress the importance of considering different types of wfh arrangements in evaluating the practicality and effectiveness of the wfh practice for example hackney et al 7 compared studies published before and during the pandemic in their analysis of the impacts of wfh arrangements on personal and organizational performance and productivity similarly yang et al 2 specifically differentiate wfh during regular work hours from wfh outside normal work hours in examining the associations between these wfh arrangements and workers wellbeing in modeling workers preference for wfh after the pandemic caligiuri and de cieri 21 have specifically focused on an involuntary wfh arrangement additionally gohoungodji et als 22 study has specifically examined the success factors of teleworking before and during the pandemic it could be expected that this body of knowledge will continue to grow given the fact that the pandemic has catalyzed a longlasting shift to wfh globally where firms reoptimize or opt for more wfh arrangements than before the pandemic 722 at another level the broader economic and social consequences associated with wfhincluding the redirection of worker spending away from city centers the declines in use and value of urban real estate and outmigration from some citieswill continue to unfold for many years to come 1 women working from home during the covid19 pandemic when millions of employees worldwide suddenly moved to mandatory wfh with no or little preparation which required major changes to their lifestyle it was expected that not all would benefit from a wfh arrangement 1 the findings in the literature hitherto are rather mixed on the impacts of wfh on both individual and organizational levels for example hackney et al 7 found that the overall impacts are less positive and could be detrimental to personal and organizational productivity and performance when an wfh arrangement becomes mandatory and full time similarly bolisani et al 23 stressed that a conclusive positive or negative verdict pertaining to a wfh arrangement was not feasible and highlighted the presence of three broad groups of employees in their cluster analysis ie those who were very dissatisfied with their wfh experience those who were very satisfied and lastly those who were neutral the disproportionate impacts of the wfh arrangement on workers may be attributed to demographic characteristics individual capabilities organizational response and policies 3 and jobrelated characteristics 72425 as gender is a key demographic characteristic there are many gendered studies on the impacts of a mandatory wfh arrangement during the pandemic on workers while it may be inconclusive to draw a negative conclusion with continued growth in the literature early empirical evidence suggests that women were disproportionately impacted by a mandatory wfh arrangement for example sharma and vaish 26 reported that the mental health of about onethird of their female respondents was moderately and severely affected along with about 80 of respondents experiencing a great increase in household chores when wfh during the pandemic lockdowns participation in home schooling was also found to be associated with adverse employment outcomes for mothers but not fathers with mothers experiencing an increased risk of losing their job and being more likely to voluntarily leave work especially if there was a need to create homeschooling contents for their schoolage children 10 in a study based in canada fuller and qian 9 reported that the conflicts between employment and care responsibilities were more challenging among mothers with children under the age of six similarly dunatchik et als 27 study in the us found that mothers were primarily responsible for childcare and home schooling even when both parents wfh a gender inequality in caregiving persisted during the pandemic this is consistent with another usbased study where mothers with young children have been reported to reduce their work hours four to five times more than fathers 28 there is also a small collection of australiabased studies reporting on similar negative experiences among the female workforce the mandate wfh experiences among the female workforce in construction have been little reported in the literature although there are a few empirical investigations on a mandatory wfh arrangement among the construction workforce in different countries the focus is on projectbased construction workers 34 or professional personnel and consultants in construction in australia based on a survey conducted around six months into the pandemic oo and lim 38 found that the unfamiliar situations and challenges faced by female workers in the australian construction industry include the mandatory wfh arrangement changes to their work location and work hours and their increased household responsibilities the top ranked challenges associated with the changes to work location and work hours were overworked working space social interactions collaboration and parenting 39 it is recognized that the wfh experiences of women working in the construction industry are peculiar because of the sudden shift to wfh necessitated by the pandemic and the low prevalence of regular and planned remote working in the industry prior to the pandemic 38 indeed the construction industry is one of the most maledominated industries with the greatest degree of gender segregation 40 the underrepresentation of the female workforce in the industry has continued to draw researchers attention to various aspects including the attraction retention and working experiences of women in the industry 41 with no exception at the time of the pandemic the female workforce in construction were facing many challenges associated with the wfh arrangement as documented in previous studies eg 45153542 these challenges are wide ranging and can be classified into individual organizational and social levels 43 the present study focuses on 22 challenges associated with the wfh arrangement research method an online anonymous questionnaire survey on the wfh phenomenon induced by the covid19 pandemic was fielded in the second quarter of 2022 ie after a series of national stateand territorybased pandemic lockdowns between march 2020 and december 2021 in australia 44 the targeted population was the construction workforce in the australian construction industry aged 18 years and above who had experienced wfh during the pandemic the survey was distributed to the authors professional and personal contacts who were also asked to further distribute the online survey link to their contacts and prequalified consultants and general contractors listed on the government registers for public sector construction procurement these recruitment strategies were deemed justifiable because there is no publicly accessible list of construction businesses in australia and a low response rate was anticipated in survey research the new south wales government public works advisory granted its permission for using their registers the online survey drew over two hundred responses from a nonprobability sample of workers in the industry for the research aim and objectives set in the present study the findings were drawn based on a subsample of the female workforce in construction the first section of the survey focused on the respondents demographic background and their domestic household responsibilities during the lockdown periods this was followed by questions on their wfh experiences prior to and during the covid19 pandemic next the questions revolved around their perceptions of the impacts of 22 challenges associated with wfh on their work activities and performance their satisfaction with the wfh arrangement and preference for wfh after covid instead of work productivity the emphasis was placed on work activities and performance due to a lack of an objective measurement of wfh productivity and the unsuitability of the conventional method based on direct measures of output and hours worked 184546 additionally individual employees wfh productivity may vary significantly under a pandemic lockdown state irrespective of the extent of their paid work activitieswhich are feasible to be performed at home 47 correspondingly the respondents selfreported wfh performance was measured on a fivepoint likert scale from i get much less done to i get much more done next the 22 challenges adapted from the literature on wfh or remote working 15354348 were worded in a neutral way for example one of the challenges was included to capture the respondents positive neutral or negative perceived impacts of this respective challenge on their work activities and performance the relevant scale used was a fivepoint likert scale of very negatively negatively neutral positively very positively and an na option since some challenges would not be appliable for individual respondents lastly their overall satisfaction with the wfh arrangement and preference for wfh after covid were measured using a single item and scored on a fivepoint likert scale from strongly disagree to strongly agree both descriptive and inferential statistical analyses were performed in the data analysis firstly a normality test was performed using the onesample kolmogorovsmirnov test which confirms that the observed variables do not meet the normality assumption therefore nonparametric inferential statistical tests were used for the data analysis these included the onesample wilcoxon signed rank test for examining whether the sample median is equal to a test value of three the correlation test to examine the association among critical challenges associated with wfh the respondents demographic characteristics and their overall satisfaction with wfh and preference for wfh after covid in identifying the critical challenges the normalized values of the mean scores and total mean score of all observed variables were calculated individual challenges of a mean score greater than the total mean score and a normalized value equal to or greater than 050 were deemed critical challenges this approach was similar to that of studies on the critical success factors results there are 78 useable response sets from female respondents for the data analysis while the sample size is considered rather small the authors are confident that the prospective respondents who were willing to respond to the online survey voluntarily were genuine in sharing relevant and informative insights on their mandatory wfh experiences indeed it is noted that a similar study focusing on the wfh phenomenon among the female workforce in the australian construction industry has also recorded a considerably low number of responses despite the support from professional bodies and construction womens networks for the recruitment of respondents 38 similarly oakman et als 32 wfh study focusing on the general population in australia used multiple recruitment strategies including paid advertisement on facebook social media and did not manage to obtain a high number of responses either table 1 depicts the respondents demographic characteristics most of them were above 35 years old and over 90 of the respondents attained a tertiary level of education approximately 75 of the respondents had over 5 years of work experience in the construction industry of whom 115 had over 25 years of industry experience at the time of the survey about 80 of respondents were working full time and they mainly worked in the state of nsw about threequarters of the respondents were employees of construction business organizations the percentages of respondents working for consultancy and contracting firms were 487 and 513 respectively in terms of their job position about 55 of the respondents were director and managerial staff and this was followed by the second largest group of administrative staff slightly over half of the respondents indicated an annual job income above aud 90000 of whom about onequarter were earning above aud 200000 in terms of family responsibilities more than half of the respondents had caring and homeschooling responsibilities during the pandemic lockdown periods almost all respondents spent time on unpaid domestic work during the covid19 pandemic lockdown periods including caring and homeschooling responsibilities if applicable the largest group spent an average of between 5 and 14 h in a typical week and about 10 of the respondents indicated an average of as high as more than 30 h per week wfh experiences prior to and during covid19 in terms of the respondents wfh experiences figure 2 shows that the majority of them worked at their company workplaces for most of their working days in prepandemic times this can be explained by the fact that about threequarters of the respondents were employees of public or private organizations who would have little say about their workplace as revealed they were new to the wfh arrangement a closer investigation shows that the four respondents who worked fully from home before the pandemic were business owners and worked in a family business during the pandemic lockdown periods the mandatory wfh arrangement was marked by a sharp decrease in the percentages of respondents working at their company workplaces in the years 2020 and 2021 respectively only slightly over 10 of the respondents worked at their company workplaces in the year 2021 correspondingly the percentages of respondents who were working partly in their company workplace and partly from home and working fully from home in the years 2020 and 2021 were 821 and 897 respectively with the covid19 pandemic lockdowns ending in december 2021 44 it can be seen that about half of the respondents were back to their company workplaces for most of their working days in the second quarter of the year 2022 nonetheless the percentages of respondents who continued to work partly in company workplaces and partly from home during this time period were about two times wfh experiences prior to and during covid19 in terms of the respondents wfh experiences figure 2 shows that the majority of them worked at their company workplaces for most of their working days in prepandemic times this can be explained by the fact that about threequarters of the respondents were employees of public or private organizations who would have little say about their workplace as revealed they were new to the wfh arrangement a closer investigation shows that the four respondents who worked fully from home before the pandemic were business owners and worked in a family business during the pandemic lockdown periods the mandatory wfh arrangement was marked by a sharp decrease in the percentages of respondents working at their company workplaces in the years 2020 and 2021 respectively only slightly over 10 of the respondents worked at their company workplaces in the year 2021 correspondingly the percentages of respondents who were working partly in their company workplace and partly from home and working fully from home in the years 2020 and 2021 were 821 and 897 respectively with the covid19 pandemic lockdowns ending in december 2021 44 it can be seen that about half of the respondents were back to their company workplaces for most of their working days in the second quarter of the year 2022 nonetheless the percentages of respondents who continued to work partly in company workplaces and partly from home during this time period were about two times higher than during the period prior to the pandemic similarly the percentages of those who worked fully from home more than doubled since the pandemic higher than during the period prior to the pandemic similarly the percentages of those who worked fully from home more than doubled since the pandemic next figure 3 shows the distribution of the respondents selfreported work performance when wfh during the pandemic lockdown periods in comparison to their normal workplace most of them reported that they were able to get at least about the same or more paid work activities done as in their normal workplace with a corresponding mean score of 3487 a onesample wilcoxon signed rank test confirms that the median of this measure is statistically above three signifying the significance of improved work performance reported by the respondents in addition approximately 60 of the respondents indicated that over 80 of their paid work activities was feasible under a wfh arrangement this was followed by the second largest group of respondents who indicated a range between 61 and 80 all in all almost all respondents were able to perform over 40 of their paid work activities during the wfh periods induced by the pandemic next figure 3 shows the distribution of the respondents selfreported work performance when wfh during the pandemic lockdown periods in comparison to their normal workplace most of them reported that they were able to get at least about the same or more paid work activities done as in their normal workplace with a corresponding mean score of 3487 a onesample wilcoxon signed rank test confirms that the median of this measure is statistically above three signifying the significance of improved work performance reported by the respondents in addition approximately 60 of the respondents indicated that over 80 of their paid work activities was feasible under a wfh arrangement this was followed by the second largest group of respondents who indicated a range between 61 and 80 all in all almost all respondents were able to perform over 40 of their paid work activities during the wfh periods induced by the pandemic perceived impacts of challenges associated with a wfh arrangement overall satisfaction with wfh and preference for wfh after covid table 2 depicts the respondents perceived impacts of challenges associated with a wfh arrangement on their work activities and performance in terms of the mean scores the normalized values and the respective ranking of these challenges the recorded mean scores range between 0658 and 0437 although high variabilities in their responses were detected with corresponding high standard deviation values ranging from 0770 to 1387 it is rather surprising to note that only as few as six challenges had negative mean scores these challenges were home schooling social interactions with colleagues communication andor collaboration with colleagues team spirit and inspiration updates on office politics and decisions and feedback from colleagues of these the median values of c4 c10 c211 c12 and c18 are statistically below zero ie perceived impacts of challenges associated with a wfh arrangement overall satisfaction with wfh and preference for wfh after covid table 2 depicts the respondents perceived impacts of challenges associated with a wfh arrangement on their work activities and performance in terms of the mean scores the normalized values and the respective ranking of these challenges the recorded mean scores range between 0658 and 0437 although high variabilities in their responses were detected with corresponding high standard deviation values ranging from 0770 to 1387 it is rather surprising to note that only as few as six challenges had negative mean scores these challenges were home schooling social interactions with colleagues communication andor collaboration with colleagues team spirit and inspiration updates on office politics and decisions and feedback from colleagues of these the median values of c4 c10 c211 c12 and c18 are statistically below zero signifying that over half of the respondents perceived these five challenges as negatively impacting their work activities and performance when wfh on the other hand sixteen challenges with perceived positive impacts recorded rather low mean scores which were only marginally above zero ranging between 0133 and 0437 although all the respective mean scores are further from one the median values of nine challenges are statistically significantly above zero this provides evidence suggesting that the impacts of these challenges on work activities and performance when wfh were perceived positively among the majority of the respondents in terms of critical challenges the results show that sixteen challenges recorded mean scores greater than the total mean score and normalized values above 050 suggesting that these sixteen challenges were deemed critical challenges for performing paid work activities under a wfh arrangement during the pandemic figure 5 shows the perceived positive impacts of the top ten critical challenges associated with wfh on work activities and performance among these critical challenges mutual trust between you and your work supervisor availability of suitable space at home and information and communication exchanges via virtual meetings ranked as the top three implying that these are important factors at play in designing and implementing a wfh work mode there are also top ranked critical challenges which are personalrelated factors namely selfmotivation and selfdiscipline work mode there are also top ranked critical challenges which are personalrelated factors namely selfmotivation and selfdiscipline the respondents overall satisfaction with a wfh arrangement during the pandemic was rather positive as indicated by a mean value of 3870 shown in table 3 similarly most respondents indicated a high preference for wfh after covid with the respective mean score close to 4 the median values of these two measures are statistically above three signifying the significance of the positive satisfaction and high preference for wfh for a greater number of respondents about half of the respondents would like to often or always wfh after covid followed by a group of respondents who would like to sometimes work from the respondents overall satisfaction with a wfh arrangement during the pandemic was rather positive as indicated by a mean value of 3870 shown in table 3 similarly most respondents indicated a high preference for wfh after covid with the respective mean score close to 4 the median values of these two measures are statistically above three signifying the significance of the positive satisfaction and high preference for wfh for a greater number of respondents about half of the respondents would like to often or always wfh after covid followed by a group of respondents who would like to sometimes work from home after covid this denotes that nine in ten respondents would like to at least be able to sometimes work from home after covid relationships among critical challenges associated with wfh demographic characteristics overall satisfaction with wfh and preference for wfh as expected the test results show that correlations exist among the sixteen critical challenges associated with wfh most of the positive correlations detected ranging between 0182 and 0803 are statistically significant at the p 001 level there are many moderately strong positive relationships between some of the critical challenges including between selfmotivation and selfdiscipline with r 0803 caring responsibilities and overall workfamily balance with r 0738 and technical or ict support and access to workrelated information with r 0750 in contrast only four weak correlations detected are not statistically significantfor example the correlations between availability of suitable space at home and mutual trust between you and your work supervisor with r 0192 addressing the relationships among the critical challenges the respondents overall satisfaction with wfh and preference for a wfh arrangement after covid on the one hand all sixteen critical challenges recorded low to moderate statistically significant positive correlations with an overall satisfaction with wfh these correlations ranging between 0310 and 0618 are all statistically significant and the strongest positive relationship is recorded for home office environment on the other hand only six critical challenges are statistically significantly related to the respondents preference for a wfh arrangement after covid in a positive way the respective positive correlations are indeed rather weak ranging between 0251 and 0313 nonetheless there is a moderately positive relationship between the respondents overall satisfaction with wfh and relationships among critical challenges associated with wfh demographic characteristics overall satisfaction with wfh and preference for wfh as expected the test results show that correlations exist among the sixteen critical challenges associated with wfh most of the positive correlations detected ranging between 0182 and 0803 are statistically significant at the p 001 level there are many moderately strong positive relationships between some of the critical challenges including between selfmotivation and selfdiscipline with r 0803 caring responsibilities and overall workfamily balance with r 0738 and technical or ict support and access to workrelated information with r 0750 in contrast only four weak correlations detected are not statistically significantfor example the correlations between availability of suitable space at home and mutual trust between you and your work supervisor with r 0192 addressing the relationships among the critical challenges the respondents overall satisfaction with wfh and preference for a wfh arrangement after covid on the one hand all sixteen critical challenges recorded low to moderate statistically significant positive correlations with an overall satisfaction with wfh these correlations ranging between 0310 and 0618 are all statistically significant and the strongest positive relationship is recorded for home office environment on the other hand only six critical challenges are statistically significantly related to the respondents preference for a wfh arrangement after covid in a positive way the respective positive correlations are indeed rather weak ranging between 0251 and 0313 nonetheless there is a moderately positive relationship between the respondents overall satisfaction with wfh and their preference for a wfh arrangement after covid suggesting that high overall satisfaction with wfh during the covid pandemic is associated with greater preference for a wfh arrangement after covid and vice versa lastly table 5 depicts the correlations among the respondents demographic characteristics their overall satisfaction with wfh and preference for a wfh arrangement after covid while there is a mix of positive and negative correlations detected between these variables these correlations are rather weak and almost all are not statistically significant at the p 005 level the only statistically significant correlation is that between the level of education attainment and preference for wfh after covid this positive correlation suggests that the respondents preference for a wfh arrangement after covid increases with educational attainment that is a higher level of education attainment is associated with a higher preference for a wfh arrangement after covid and vice versa discussion first the exploratory findings provide evidence on the low prevalence of regular and planned remote work among female workers in the construction industry before the pandemic as claimed by oo and lim 21 however the evidence indicates that a wfh arrangement especially a hybrid modeworking partly from a company workplace and partly from homeis likely to stay in the industry based on the reported statistics indeed a hybrid mode with some paid workdays at home was found feasible and perceived as favorable by employees in some recent studies across different countries and with nine in ten respondents expressing a wish that they would like to at least be able to sometimes work from home after covid it should be noted that the selfreported percentage of work which was feasible under a wfh arrangement was based on the respondents assessment of their job tasks but not their occupations which were found unhelpful in explaining the viability of wfh practices 25 dingel and neiman 47 reported that the teleworkable ratio for construction occupations has been reported below 25 similar to those in other industries such as agriculture manufacturing and retail trades nonetheless while the respondents were not asked to state their job tasks and activities in the survey the relatively high selfreported percentage of work which was feasible under a wfh arrangement could partly be explained as many of the respondents were director managerial and administrative staff these respondents were mostly likely officebased staff for most of their working days before the pandemic in terms of the impact of a wfh arrangement on work activities and performance the positive trend of the respondents selfreported wfh work performance including improved work performance among nearly half of the respondents is again rather consistent with the respective percentages reported in aksoy et als 1 global survey in 27 countries and parry et al s 46 study in the uk correspondingly the current findings also recorded statistically significantly high overall satisfaction with a wfh arrangement which is positively related to the respondents preference for wfh after covid reechoing the findings by beck and hensher 5 and deole et al 24 it is noted that female respondents in ahmadi et als 51 study were more satisfied with a wfh arrangement compared to male respondents similarly aksoy et al 1 found that women valued a wfh arrangement more than men nevertheless it is unquestionable that the sudden shift to a mandatory wfh arrangement induced by the pandemic will bring with it challenges and obstacles this phenomenon is well demonstrated in the present study by the respondents mixed perceptions of the impacts of challenges associated with a wfh arrangement on their work activities and performance along with high variabilities in their responses a plausible explanation of these observations is that the challenges would have impacted individuals to varying extents especially since they were facing different circumstances and many personal factors were at play including their domestic household responsibilities on the one hand it could be expected that the respondents would be learning by doing in dealing with the challenges associated with the mandated wfh arrangement and that they would be confronted with either positive or negative outcomes on the other hand the overall perceived impacts which are positive for sixteen challenges seemingly suggest that the respondents were able to maneuver the challenging situations and realize the potential benefits of wfh for example the mean scores show that the overall workfamily balance has a perceived positive impact echoing the reported positive experience of overall workfamily balance among wfh construction workforce in pirzadeh and lingards 34 and ogunnusi et als 36 studies this could be explained because a wfh arrangement offers employees the flexibility to organize their daily routine while managing their family responsibilities and there are many other potential benefits 51143 along with various coping strategies for realizing the potential benefits of wfh 3951 respectively authors reported high job satisfaction under wfh arrangements during the pandemic all in all the findings indicate that the female respondents were adapting well to the sudden shift to a wfh arrangement despite some challenges which recorded negative perceived impacts these challenges included home schooling social interactions with colleagues and communication andor collaboration with colleagues indeed these recorded negative factors are rather anticipated for example it is likely that the impacts of a wfh arrangement and home schooling are mutually reinforcing creating new and demanding situations for many petts et al 10 found that home schooling during the early stage of the pandemic was associated with negative employment outcomes for mothers but not fathers in terms of difficulties in communication and the lack of social interaction and effective communication these are all the drawbacks of remote working which have been reported in previous studies published prior to the covid19 pandemic 43 as well as studies conducted during the pandemic although all six challenges of perceived negative impacts are not deemed as critical challenges these negative factors should nevertheless be addressed by organizations continuing with a wfh arrangement after covid conversely the correlations existing among the sixteen critical challenges of perceived positive impacts suggest that these challenges are interrelated and highlight the need for pragmatic strategies to incorporate them in the design and implementation of wfh practices lastly the absence of associations between the critical challenges and preference for wfh after covid suggests that there could be many other factors affecting employee preference for wfh the predictors identified by caligiuri and de cieri 21 are the extent of worklife conflict and need fulfilments this may also explain the absence of associations between most of the demographic characteristics and preference for a wfh arrangement after covid as revealed in the present study research implications given the low prevalence of the wfh practice in the construction industry before the pandemic it is unarguable that the limited studies on wfh experiences among construction workers are crucial in providing useful insights for employment organizations and laying the groundwork for further studies the current exploratory study as one of the limited studies offers preliminary evidence on an overall positive wfh experience for the female workforce in the construction industry indeed the findings are rather surprising since women have been found disproportionally impacted in different aspects due to the mandatory wfh arrangement in several australianbased studies in terms of the type of jobs and tasks the team dynamic and the evaluation of wfh effectiveness and productivity 7 for the research community the findings clearly have implications for further explorations of the relationships found in the present study including examining the respective causal effects between variables conclusions as one of the very few studies on mandatory wfh experiences among the female workforce in the construction industry the findings provide a firsthand insight which is valuable to both employment organizations and the research community the results show that most of the challenges associated with a wfh arrangement recorded positive perceived impacts on work activities and performance signifying that the respondents were adapting well to the sudden shift to mandatory wfh arrangements induced by the pandemic although most of the respondents were new to a wfh arrangement there is evidence suggesting their positive satisfaction with a wfh arrangement along with perceived positive work performance while wfh about 90 of respondents would like to at least be able to sometimes work from home after covid which is positively correlated with the level of education attainment these findings lay the groundwork for future studies on wfh practices exploring the various relationships revealed in the present study in addition the top critical challenges identified associated with a wfh arrangement along with a set of negative factors might be useful for employment organizations to reoptimize their wfh practices nonetheless one of the key limitations of this study is its small sample size which may reduce its exploratory power and the generalizability of the research findings although a low response rate is expected in online surveys further studies could consider different sampling techniques such as obtaining support from employers in distributing the online survey in addition researchers could consider using qualitative approaches such as an interview and focus group discussion to further explore the wfh experiences of women in the construction industry next future studies could explore other perspectives of different wfh arrangements including the opportunities and obstacles to wfh among different cohorts of construction workers indeed there are many other aspects of wfh in the context of the construction industry which should draw researchers attention including the gender differences in wfh experiences the possible objective measures of personal and organizational performance and productivity when wfh the challenges presented to the firms human resources management in implementing wfh or hybrid work mode the roles of organizational support and control in employee wfh experiences and performance the determination of an optimal hybrid work mode and the factors contributing to successful implementation of wfh arrangements data availability statement the data is not publicly available due to ethical reasons

early studies on the covid19 pandemic suggest that the working from home wfh mandate and unusual caregiving arrangements have dramatically impacted the employment of women especially those with young children this study explores womens perceptions of the wfh mandate arrangement data were collected from the female workforce in the australian construction industry using an online questionnaire the specific objectives were to i explore their wfh experiences ii examine their perceived impacts of wfh challenges on work activities and performance and iii explore the relationships among critical challenges the respondents demographic characteristics and their overall satisfaction with wfh and preference for wfh after covid although most respondents were new to the wfh arrangement there is evidence suggesting that they were adapting well to the sudden shift to a wfh arrangement sixteen out of twentytwo challenges recorded positive perceived impacts on work activities and performance the top three critical challenges were i mutual trust between you and your work supervisor ii availability of suitable space at home and iii information and communication exchanges via virtual meetings the respondents also indicated positive satisfaction with a wfh arrangement along with perceived positive work performance while wfh most of them indicated high preference for wfh after covid which was positively correlated with the level of education attainment the critical challenges identified together with a set of negative factors might be useful for employment organizations to reoptimize their wfh practices

introduction struggle scarcity and sacrifice in students life let the flame of revolution rise everywhere let the present social order be burnt down and let a new world be born first time i encountered with these lines in my final semester of ba major english these lines saddened me a lot as my student life was also synonyms to scarcity poverty and immediate needs of money and materials more often financial social and cultural status of an individual determines how to practice and celebrate rituals marriage and birthday celebration the way a rich and poor celebrate birthday differ on the sociocultural and financial status this autobiographical story raises the number of questions like does birthday matter same to rich and poor does society treat vaikom respectfully on his birthday is a saying friend in need is friend indeed really applicable to the narrator in this paper i exhumes how poverty and scarcities leads narrator to examine and evaluate the neighbours relatives and friends their behaviours and gaze to see a poor student fighting to join hands to mouth drawing upon the argument of social realism theories especially of george lucks who views poverty as not only about income it is about the deprivation of economic and social rights insecurity discrimination exclusion and powerlessness poverty is an omnipresent problem that abandons class consciousness in poor people leaving them in alienation frustration and disjunction as lucks states above the disappointed factor in narrators life in nonother than the classthe rich who holds sociopolitical power in the society published in the year 1944 vaikom muhammad basheers short story birthday provides a detail and vivid account of his own birthday in first person narration i a day when he has no money to buy even a cup of tea narrating in personal tone i vaikom portrays his own real life events and incidents that happened in his college life the story mesmerizes readers as it focuses on just one day in a mans life a day for celebration but when he has no money for food and is trying to fill his stomach by scrounging a meal off any of his acquaintance the poor person only knows actual meaning of poverty and human sufferings this suffering leads them to hold the faith that financial equality must be gained by blurring socioeconomic notion of power jo goodwin parker an american writer in her essay what is poverty states that financial suffering is heart breaking throughout the hole and corner of the world she further states poverty is staying up all night on cold nights to watch the fire knowing one spark on the newspaper covering the walls means your sleeping child dies in flames poverty is hoping it never rains because diapers wont dry when it rains and soon you are using newspapers poverty is seeing your children forever with runny noses paper handkerchiefs cost money and all your rags you need for other things even more costly are antihistamines poverty is cooking without food and cleaning without soap parker and vaikom represent the financially deprived people whose winter and summer respectively goes on fire site and leakage roof no birthday anniversary or any special day for them rather only special thing for them is to join hands to mouth though the phenomena of expressing pain and suffering are quite common in life narration but vaikoms portrayal of poverty and alienation encompasses the common problem that many financially deprived people experience in their everyday life the readers follow the narration from one encounter to another and observe the attitudes of various people towards the narrator and throughout it all there are the police and the cid agents who take him in for the questioning regarding the domination of poor people marxistfeminist lillian s robinson remarks due to the existed doctrine of rich and poor many people rarely hesitated to question most other established institutions and veritiesis due to the preference for a heroic icon over an understanding of how the representation of such an icon derives from and servesas well as challengesthe dominant social forces perhaps it is fair to say that marginalized people that includes feminists behave as if they are unconvinced that cultural studies is a useful political weapon whereas the value of the icon goes unquestioned even though the narrator is well known to the neighbours and friends but they treat them as a strange one this strangeness is indirectly guided by money and materials that clearly draws demarcation line in proletarian society hamid an intimate friend invites him for dinner on the birthday night but disappears when narrator approached at his house this act of disappearing and deceiving the poor is quite common in class base society that treats people not on the personal and professional basis rather on the monitory bases this monetary value leads poor people to revolt against the have people either by stealing looting or capturing the property same thing happened in this story as well where to stave off his hunger and with no possibility of gaining a meal by honest means he is forced to steal from one of his neighbours this act of stealing instigates to be strong and bold to challenge being objected discriminated and neglected by the nearest and dearest friends and acquainted people reflection of social and economic insensitivity of friends and acquaintances in birthday being dependent on the political and historical aspect of society social realism is constantly evolving and changing as per the changing scenario of the time it is a representative form of art in which real events incidents and activities often take place the word social refers to the people in the society and realism refers to the way these people are portrayed in each medium here medium denotes the way of representation whether through the print materials sculptures or created arts that represents society culture and traditions of an individual social realism gives accurate portrayal of the scene and characters without embellishments and real sociocultural impacts can be seen in these lines in the story where the narrator exclaims my acquaintances passed me by without seeming to see me oh my friends this is my birthday wish me happiness on my birthday i whispered in my heart the shadow passed me by why was it that my friends did not speak to me on seeing me social realism as a theoretical tool depicts life of an individual in relations to existing social context set of rules and principles that molds and guides an individual this realistic presentation of an individual inspires common people to be aware of their rights and duties literature being mirror of a society must incorporate realistic picture pain and pathos emotions and sentiments that dwells in real life experience khwaja ahmad aabhas a fierce advocate of social realism states social realism then is the acute awareness of the social forces that surround the individual their power to influence the lives of men and womenfor better or for worse and the overall interaction of the individual and the society in this way matthew a selfish friend of narrator represents the social agencies institutions and organizations that always hypnotize guide and mobilize as per their wish narrator though seems so furious in the story but fails to take any action against deceptive and helpless friends and neighbours due to the lack of financial position narrator fails to take any action against the promising friends who assured him to help in time of need social realist texts attempt to convey a message or at least awareness about an issue or problem through a single image birthday also contains realistic picture of modern youth their insincerity and indulgence unethical activities vaikom reaffirms what is wrong with the world parents toiled and sent money regularly every month with that money the young people received their education and there were also cigarettes tea coffee ice cream cinema cuticura powder vaseline costly clothes expensive foods syphilis gonorrhea there were the citizens of the future rulers and legislator what was wrong with the world by throwing the light on then indian society the story birthday provides interesting insights into the life of a poor person who thought not obviously poor is stricken by poverty which is doubly crippling because it is invisible to his friends and acquaintances this autobiographical story incorporates the social realism that has always been predominant in our society but not noticed to common people as they are guided by rules set up by powerful people power whether financial or political is always provisional and temporal in nature in examining time and temporality in indian society that is still backward the author shows how the conventional temporal sequence of a past present and future dominates with little consideration being given to time as a multiple rather than singular concept vaikom compares and contrast differences in the temporal aspects of mainstream set of rules and identifies a changing concept of the time he remarks how much cruel is the time there is no oil in the lamp in my room and there is a great deal to write that is why i got out my bed and have come and sat under this lone lamp near the lake side and began to write while things are still fresh in my mind moreover the memorizing act is so dominant in the story that the narrator doesnt remain silent or passive when encounters the hatred and humiliations of matthew hamid mr p gangadhar and two unknown boys on the auspicious day of the birthday henry james explains about realism and role of power to guide the life of civilians in his essay the art of fiction and argues that it is quite difficult to find the invisible power embedment in society according to him whatever we do they are all perceptions created by people with power and prestige james writes i am far from intending by this to minimize the importance of exactnessof truth of detail one can speak best from ones own taste and i may therefore venture to say that the air of reality seems to me to be the supreme virtue of a novelthe merit on which all its other merits helplessly and submissively depend if it be not there they are all as nothing and if these be there they owe their effect to the success with which the author has produced the illusion of life james says that a work of art if based on truthful and worthy incidents and describes the social realism it provides enough proofs and evidences to the social critics to visualize the mirror image the ideal views in any work of art do not work according to him due to direct and indirect influence of the social structures on the contrary as argued by james it is quite difficult to trace exact reality in the world because nothing can be exact reality reality is always behind the curtain whatever people claim to be real it is only interpretation but some are close to real while others are far from reality social sensitivity explores the proficiency at which an individual can identify perceive and understand the context where personal or social interactions take place respectfully in the cordial manner on contrary social insensitivity promotes and praises the sense of strangeness hatred and jealousy among the people this sense of superior and inferior feeling as explained in nigerian novelist chigozie obioma creates inferior feeling by abandoning the hopes and expectations needed in life chinoso a narrator in his novel orchestra of minorities expresses his agony of being poor like vaikom in the story birthday chinoso expresses his agonies as below when a man encounters something that reminds him of an unpleasant event in his past he pauses at the door of the new experience carefully considering whether or not to go in if he has already stepped in he may retrace his steps and reconsider whether to reenter like my host every man is inextricably chained to his past and may always fear that the past might repeat itself the sense of anger is not different to a person whose life is full of pain and burdens of being poor gangadhar a friend of vaikom coincidently meets him on the birthday gangadhar becomes so insensible that he demands donation for the rally to march against the government vaikom being the penniless reaffirms i dont have even an aana it is several days since i have eaten a morsel today is my birthday i havent eaten anything so far ganga if you can help me in this situation gangadhar being the rich and active in politics doesnt pay much attention and insists that either financial donation or physical participation in political rally is needed stop joking and listen and listen to me there is great trouble some three thousands workers have gone on strike they have been starving for a week and half there may be great trouble this harsh remark reiterates that poor people are always victim of rich people threat and fear they have to obey their neighbours in any cost otherwise they can be ostracized from the neighbourhood another incident of age based social insensitivity is described in the party where his close friends celebrate the party without inviting the narrator vaikom satirizes falling indian ethics and human values in connections to the youths party which gets arranged without any purpose on the money send to them by their family members vaikom further states six o clock a beautiful evening the setting sun was like a bob of blood swallowed by the sea… the western sky was filled with golden clouds the ocean seemed shoreless nearer the rippling lagoon its shore was so peaceful young dandies smoking cigarettes were promenading there and young ladies dressed in gorgeous saris with glancing look and shy smiles on their faces were resting there one could hear hearteasing broadcast songs from erotic films the gentle breeze carried fragrance from flower… but i was almost fainting it is not very clear in the story that whether the young participants really took part in any sort of celebration or that was casual gathering but one undeniable fact is that the saying a friend in need is friend indeed is not at all applicable in case of financially weaker section of the friend like vaikom modern world states sv srinivas in the essay politics of failure creates the spikes of conspiracies through the means of western education system that only provides certificates than characters and morality the creation and recreation of institutional mechanism to control the voice of people always make the more poor and helpless he questions the reliability and relevancy of the colonial education systems that has completely replaced the sanskrit based hindu education system he further writes the humanistic aspect in our youths is almost at the vanishing point the major blaming factor is education that neglects humanistic approach in curriculum the obstructions offered to the acquisition of knowledge in the discipline closes the open ground for the students real life experiences the impacts of sociocultural educational system also has been at the center of the story birthday police for instant arrested him and interrogated him for an hour they accused him of inciting the public mob against the administration the narrator in the story denotes brutality of police in following lines volume4 number1 asar 2076 after an hour of police interrogation i returned to my room sat in the darkness and perspired profusely no light in my room today how can i get kerosene oil i must have something to eat to abate my hunger do police really protect helpless people like me money i think is most important to modern peoplean instrument of happiness government institutions like police always expected to be protective and savior of the civilians on contrary this story indicates that the major cause of vaikomrepresentative of common peopleis lack of sociopolitical awareness the financial status in developing nation is one of the main causes of human suffering and vaikom is not an exception he has tried his level best to depict vivid explanation of the ups and downs that common people face in their everyday life due to lack of money indians have to face socioeconomic problems for the long time before independence british had controlled all financial resources and even after independence indirectly they have dominates financial activities through the social and political institutions these institutions create the discourse of power and hierarchy on the basis of the money materials and majority they do have in society these legacies still create divisive walls among the people in name of caste and religion money and materials power and party financial activities vaikom being postindependent writers tries to create the memory experience pain and suffering of common people as a social realistic story birthday portrays the financial problem that many of the students go in their student life moreover the bond of friendship is important in this time and when our own friends turn deaf ears towards us we remain helpless like vaikom still expecting their help which rarely come true in lifetime conclusion though equality and justice has become a catchword in realistic stories treatment on the basis of money materials and power are significant challenges among the voiceless and choiceless people in many of the third world countries besides the other aspects of social justice behaviors on the basis of financial and social position often cause social tension vaikom tries to analyses upon the public gaze that targets needy and poor people this story provides a detailed and vivid account of the birthday of the narrator who has no money even to by a cup of tea on his birthday this story emphasis upon the need to enhance sense of oneness human relations based not only on money and materials rather on people to people relations their needs and basic necessities by incorporating the concern of every individual in the society vaikom is able to portray socialeconomic reality

this paper explores the plight of a poor student who doesnt have a penny to celebrate his birthday janmadinaa birthday is a story originally written in malayalam narrated from the autobiographical perspective vaikom muhammad basheer the narrator makes the readers observe pathetically different encounters with his friends and neighbours his friends and neighbours look at him with strange gaze and deny lending him even an anna rupee to have a morsel of food and a cup of tea on his birthday vaikom has varieties of groups of characters the poor the students and the helpless and rich people through the perspective of social realism social realism by george lukacs describes socioeconomic reality that rejects the deterministic relationship between the reality and its underlying meaning largely this article deploys lucakss concept to explicate vaikoms story and reflects upon the issue of pretty misery of the protagonist the story encapsulates an optimistic remark that the poor people always remain active and raise voice against the socioeconomical domination from the elites

introduction rangers are at the frontline of efforts to conserve biodiversity around the world the estimated 15 million rangers who are currently active can have a variety of diverse roles and responsibilities yet all of them work towards ensuring that wildlife and other natural resources are being protected for instance rangers may be involved in engaging local communities in biodiversity conservation wildlife and general law enforcement supporting tourism activities and recreation biological monitoring relocating wildlife collecting managing and analysing data mitigating humanwildlife conflict providing education and awareness andor guarding national borders the international ranger federation defines a ranger as someone who is responsible for safeguarding nature and cultural and historical heritage and protecting the rights and wellbeing of present and future generations and who provides recreational opportunities and interpretation of sites while providing links between local communities protected areas and area administration given the nature of their work rangers often work in challenging and dangerous conditions including the threat of encountering armed intruders dangerous wildlife extreme weather conditions and contracting infectious diseases previous studies have investigated the impact of individual ranger characteristics role complexity role progression and hazardous work environments on rangers safety health occupational stress wellbeing and job satisfaction a growing body of literature has examined or discussed the impact of factors such as employment relations income level workplace rights and protections and other employment aspects including schedule predictability and working hours on rangers health and other wellbeing indicators thus addressing the wellestablished links between employment conditions and workers health given the wide range and complexity of employment arrangements and contextual factors that could affect rangers health and wellbeing the accurate study of related exposures and outcomes requires a systematic and consistent approach that uses established theoretical frameworks and operationalizations for instance in an effort to address previous research limitations related to the exclusion of employment conditions from occupational health research on working conditions along with study design deficiencies and biased assessments of employmentrelated exposures the concept of precarious employment is increasingly used to define and categorize employmentrelated factors and study their impact on workers health and wellbeing currently there is no accepted definition but instead many explanations and approaches are used to define precarious employment which can lead to several methodological challenges especially when trying to compare and combine findings across regions economic sectors and population subgroups within the fields of public health and social and occupational epidemiology precarious employment has been described as a multifaceted construct that includes employment insecurity income insufficiency and lack of rights and protection in the employment relation including no protection against problematic working conditions employment precarity could be located on a continuum with standard employment characterized by fulltime nonseasonal and unlimitedduration contracts at one end and a high degree of employment instabilityincluding contractual relationship insecurity and temporariness income insufficiency and lack of rights benefits and protection in the employment relationshipat the other end although as a determinant of population health and health disparities precarious employment conditions could affect workers in all economic sectors and in all countries around the world its prevalence is higher among certain occupations and populations as substantiated in a range of studies discussing the impacts of precarity on diverse population subgroups precarious employment is unevenly distributed being more prevalent among groups that experience other types of socially created inequities related to for example race age gender income class education immigration status and disability the number of studies examining both the relationships between precarious employment conditions and health 1 3 outcomes and potential interventions to eliminate and minimize precarious employment conditions or at least mitigate its impacts on workers and their families has increased considerably in recent years rationale for study and contribution to the field the aim of the present study is to assess whether the precarious employment conditions of rangers have been examined within recent conservation criminological and environmental sustainability publications through a preliminary literature search we identified that the concept of precarious employment is rarely used in relation to rangers yet conditions which are typical of precarity are commonly reported in this literature without being labeled as such we sought to address this knowledge gap by conducting a scoping review to gather research from around the world and explore a series of interrelated knowledge gaps given the multitude of roles played by rangers in conservation efforts and environmental sustainability an increased understanding of the ways in which precarious employment affects them could guide the development of suitable interventions and inspire further research that builds on this theoretical framework and measurement of occupational exposures a focus on rangers employment and working conditions would also be in alignment with the ongoing sustainable development agenda promoted by global institutions such as the international labour organization which view decent work as a way of stimulating economic growth fighting poverty and reducing disparities the need for such research is further supported by the recent worldwide economic crisis triggered by the covid19 pandemic which brought increased attention to the vulnerability to infection of workers in precarious employment and the range of severe short and longterm consequences these workers are likely to experience importantly we suspect that the impacts of the precarity of ranger employment conditions may extend beyond the wellbeing of the rangers themselves rangers who do not have adequate employment security benefits rights supports and protections may be limited in their ability to sufficiently carry out their duties protect biodiversity and support local communities they may also be more susceptible to misconduct and corruption including being drawn into the illegal wildlife trade improving the employment conditions of rangers is especially critical in biodiversity hotspot regions and regions with high species richness and endemism where insufficient efforts to protect wildlife may have global repercussions for these reasons research is needed to understand the severity of precarity in ranger employment around the world and how best to address this occupational health risk scoping review questions our review addressed the following questions q1 how is precarious employment conceptualised with regard to rangers q2 how do the precarious employment conditions of rangers differ geographically q3 which of the various aspects of precarious employment conditions of rangers have been examined in the literature q4 how does precarious employment impact the mental and physical health of rangers q5 what are the consequences of not improving the employment conditions of rangers q6 what can be done to improve the employment conditions of rangers material and methods our scoping review protocol was developed using the methodological framework put forth by peters et al the prisma 2009 flow diagram is used to illustrate the article selection process and the specifics related to source selection duplication inclusionexclusion and fulltext review eligibility criteria population the review includes publications focused on rangers and synonyms and excludes publications focused on other conservation or law enforcement workers concept we included publications focused on precarious employment to qualify for inclusion a publication had to either specifically mention the term precarious employment or explore any of the following four dimensions of precarious employment employment insecurity income inadequacy lack of rights and protection and problematic working conditions studies that did not discuss the employment and working conditions of rangers which focused on the status and protection of wildlife or protected area rather than discussing the rangers work or studies focused on job satisfaction or income level without exploring any of the domains of precarious employment were excluded for this scoping review we defined precarious employment as a multidimensional construct encompassing dimensions such as employment insecurity individualized bargaining relations between workers and employers low wages and economic deprivation limited workplace rights and social protection and powerlessness to exercise workplace rights and organized the precarious employment domains building on findings from a recent systematic review of precarious employment definitions and measures in addition to the three dimensions highlighted in kreshpaj et al namely employment insecurity income inadequacy and lack of rights and protection we also focus on problematic working conditions and within each dimension we focus on several themes that are relevant to rangers employment such as accommodations and living conditions context we included publications examining rangers working in the context of parks conservation areas protected areas game reserves wilderness areas and nature reserves in any geographical or socioeconomic context publications focused on rangers who do not work in these contexts were excluded the context was intentionally kept broad as we wanted to include all possible contexts that rangers may work in the international ranger federation considers rangers to work broadly in wild areas historical and cultural sites and in protected and conserved areas and wider landand seascapes therefore we did not want to exclude potentially relevant results based on strict categorizations of geographical space outcomes we also included publications that examined the health of rangers and their families in the context of their employment and work conditions but excluded publications that focused on the impact of individual characteristics of rangers other included publications focused on the possible nonhealthrelated consequences of not improving the employment conditions of rangers such as increased environmental crime hwc and corruption publications examining such outcomes without discussing at least one domain of precarious employment were excluded interventions we also included publications that discussed either proposed or existing initiatives that could generally improve the employment conditions of rangers publications describing initiatives focused solely on leadership training ranger motivation or job satisfaction were excluded types of sources english language publications published from january 2000 to june 2021 using any research design peerreviewed or nonpeerreviewed including thesesdissertations press releases and working papers nonenglish language publications and english language publications published before january 2000 or after june 2021 books and book chapters conference abstracts conference papers and proceedings trade journals and wire feeds videos and encyclopedias and reference works were all excluded search strategy we selected four comprehensive and interdisciplinary scholarly databases and ran a search query on these databases which resulted in 462 records as follows web of knowledge scopus medline and proquest we also identified grey literature reports posted on the websites of relevant organizations and ranger associations our list of organizations included african wildlife foundation african parks conservation defenders of wildlife ecoamericas environmental investigation agency european ranger federation freeland foundation game ranger association of africa global environment facility global initiative insight crime ifaw international institute for environment and development international labour organization international ranger federation international union for conservation of nature oecd panorama solutions people not poaching ranger federation of asia the thin green line foundation traffic unep usaid wildlife conservation society world animal protection world wide fund for nature in addition we searched for online publications from members of the international ranger federation that had websites the search query consisted of terms identified by the authors to describe rangers the concept of precarious employment and its domains and possible outcomes the search strategy was tailored for each academic database and each reviewed website a sample search strategy used for the web of knowledge database is included in the supplementary information section we then used snowball sampling of the reference list publications to identify additional citations and possibly relevant papers study selection the search results were imported to covidence the online systematic review collaborative platform and deduplicated in covidence every paper was first screened by its title and abstract by at least two members of the author team an initial pilot test was conducted and a screening guidance table was created and used to ensure consistency of the inclusionexclusion decisions among reviewers the full texts of articles included at the titleabstract screening stage were reviewed and further screened into 92 eligible publications the review of reference lists of included studies resulted in 7 additional relevant papers of which 6 were eligible for inclusion in our final results hence the total number of papers included in our scoping literature review was n 98 data extraction the covidence platform was used for the fulltext screening stage conducted independently for each study by two reviewers and any discrepancies were resolved through discussions among reviewers an excel spreadsheet data extraction form was developed and used for this review to enable the compilation of all extracted data into one document the extraction categories included details related to each studys author title year of publication country geographical area covered as well as specific details relevant to each review question an initial pilot of the data extraction tool was conducted by members of the review team and tailored accordingly data analysis and presentation given the exploratory nature of this scoping review analysis did not include a critical appraisal component the findings are presented using a combination of text graphs and other visuals results and discussion how is precarious employment conceptualised with regard to rangers we found that overall there has been little empirical research on the employment conditions of rangers over the past 21 years although the number of studies has been rising over time especially in the grey literature in addition only 2 of the 98 papers included in this review used the term precarious yet all papers discussed at least one dimension of precarious employment although very rarely referring to it from this perspective for example thakholi conceptualised the precarious employment of rangers using concepts and terms such as lowskilled jobs gigs and lack of contracts low income racial divides in labour conditions social deprivation and the lack of rights and protection the second publication to mention the concept of precarious employment with regard to rangers was a news report by the european ranger federation this publication detailed the story of a spanish ranger who was almost killed after being attacked by an axewielding cattleherder pointing to existing limitations of rangerrelated legal frameworks and the need for statelevel legislation to improve the safety of rangers these findings reveal that the construct of precarious employment is very rarely used in the literature on rangers and instead various employment conditions affecting the health and wellbeing of workers are usually studied separately as will be discussed in more detail in sect 33 failing to account for all employment conditions affecting workers andor studying these conditions in isolation makes it difficult to accurately measure the impact of precarious employment conditions on health understand the mechanisms of interaction between such conditions and health outcomes and identify relevant and sustainable solutions to eliminate or minimize precarious employment this identified gap suggests that conservation and wildlife law enforcement researchers would likely benefit from more interdisciplinary collaborative research to better understand the consequences of precarious employment on rangers health and on efforts to protect biodiversity as well as possible ways to improve the employment conditions of rangers and other conservationists how do the precarious employment conditions of rangers differ geographically studies on the precarious employment conditions of rangers have been conducted in nearly every major geographic region and in 84 countries in total hotspot regions for research on ranger precarity include southern eastern and central africa and south and southeast asia in particular the democratic republic of the congo received the most reporting on precarious employment of rangers particularly in virunga and garamba national parks other frequently mentioned countries include uganda cambodia india indonesia kenya united states nepal thailand vietnam zimbabwe bhutan china myanmar and tanzania figure 4 summarises how much attention has been paid to each specific theme within four dimensions of precarious employment by major world region regionspecific examples will also be discussed below throughout sect 33 which of the various aspects of precarious employment conditions of rangers have been examined in the literature employment insecurity twelve papers explicitly discussed employment insecurity aspects a large survey on the working conditions of rangers found that over 23 had nonpermanent temporary contracts while regional reports recognized that 35 of rangers in central america and 38 of rangers in asia were temporarily employed this is important as rangers that are on shortterm contracts are likely being deprioritised for equipment and training as a result furthermore 38 of countries surveyed in the world wildlife funds ranger insurance report employed rangers on temporary contracts without providing employmentrelated insurance coverage not surprisingly the covid19 pandemic has reportedly exacerbated the contractual relationship insecurity of rangers across various regions as the halt in tourism activities has diminished the primary source of funding for rangers and conservation efforts in many countries many rangers were forced to reduce work activities or stop them entirely including antipoaching patrols and community outreach in addition 20 of rangers lost their jobs due to budget cuts as a result of the pandemic several studies mentioned that rangers are often underemployed and generally lack opportunities for career advancement in some cases rangers reported that the few promotions available were unfair and offered based on personal biases resulting in favouritism tribalism and nepotism rangers may also be unpredictably transferred to new outpost stations for irregular and uncertain periods of time in addition the average duration for fig 3 global distribution of english language publications on topics related to the precarious employment conditions of rangers by country january 2000june 2021 postings of wardens is short which is too short for them to become thoroughly familiar with the park situation and become effective at their job moreover a small number of rangers held other paid jobs besides being a ranger income inadequacy our results suggest that rangers experience income inadequacy frequently as this was emphasised in 30 papers the most commonly discussed form of income inadequacy was low income level many studies found that rangers did not feel they were paid a fair wage especially given the dangers associated with the job rangers may not even be able to bring some soap home after completing an exhausting and hazardous field mission rangers are typically paid less than other law enforcement officers despite facing lifethreatening conditions such as armed intruders and dangerous wildlife in isolated contexts covid19 has led to further reductions in pay and reduced salaries for rangers globally researchers found that often rangers stay in their jobs despite receiving insufficient salaries because they feel they have limited employment options and consequently could be exploited by their employers particularly in private nature reserves the other major aspect related to income inadequacy is income volatility eleven studies described how rangers received irregular late and devalued payments which indicate the presence of employer abuse and exploitation which is illegal in many countries thirty three percent of rangers surveyed in 28 countries were paid late at least once in the past 12 months while 7 of rangers had their payment withheld for over 2 months and 4 had their salaries canceled entirely for example burkinabé rangers are paid low wages that are based on a meritocratic system and occasional payments rather than a regular salary income volatility is linked to other aspects of precarious employment such as normalization of overtime as rangers sometimes are not paid beyond regular hours even after working 12h days in the bush income volatility is another dimension of precarious employment that has been exacerbated by covid19 in addition to increasing an individuals risk of experiencing poverty the combination of low income and high income volatility can have direct fig 4 ag regional distribution of english language publications on topics related to the precarious employment conditions of rangers january 2001june 2021 using the world health organisations categorization of regions severe implications for rangers health wellbeing motivation good governance and ability to prevent wildlife crime lack of rights and protection 3331 lack of social security our results suggest that there is a severe and widespread lack of workplace rights and protections available for rangers as this was outlined in 54 of the included studies a common theme identified was a lack of social security benefits according to the literature the majority of rangers lack health insurance life insurance longterm disability coverage and workplace pensions meaning that if a ranger has a workrelated injury or even death there would be no support available rangers also lack medical support when dealing with illnesses that are common in their line of work the severity of the situation was wellcaptured by stellar who pointed out that ranger employment conditions and the lack of social support are contrary to article 25 of the universal declaration of human rights which states that everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family including… necessary social services and the right to security in the event of unemployment sickness disability widowhood old age or other lack of livelihood in circumstances beyond his control at a global level the ranger insurance report found that rangers have no health insurance coverage in 20 of the countries surveyed no life insurance coverage in 35 of countries and no longterm disability coverage in 45 of countries in the most extreme yet unfortunately not uncommon example when rangers are killed while on the job their families may be left vulnerable to a life in poverty government welfare or insurance is often inadequate or nonexistent for the partners parents and children of rangers who die on the job interestingly some studies reported that the available social supports are less than the support that police military coastguards and firefighters receive despite rangers facing the same or higher degree of risks and hazards these inadequacies are prevalent across multiple regions although africas rangers in particular may receive the least social support unsurprisingly given both the importance and the dangerous nature of rangers work advocacy efforts promote at least full insurance coverage for all rangers rangers generally lack access to regular leave days which can include sick leave domestic leave bereavement leave and parental leave the 2019 global life on the frontline report found that 45 of rangers do not get paid sick leave and 31 do not get paid annual leave additionally 77 of rangers do not receive overtime compensation and 78 of rangers are denied extra pay for dangerous work conditions though lacking research attention there are several gender dimensions concerning the lack of social support for rangers particularly for rangers who are mothers for instance female rangers have reported that they have a higher burden of childcare and constantly feel worried about their childrens supervision and wellbeing while out on patrol especially during patrol trips which can last several weeks article 25 of the universal declaration of human rights also states that motherhood and childhood are entitled to special care and assistance however pregnant rangers may feel they have to continue going on multiweek patrols throughout the majority of their pregnancies due to the lack of support available low levels of unionization we found only four papers that explicitly discussed the issue of unionization nearly half of all rangers in two global surveys responded that they did not have access to a union or similar body that could represent and collectively bargain on behalf of rangers a study in south africa found that although many park employees were in fact members of a union there was little confidence in the effectiveness of unions in addition given the size of protected areas limited transportation and amount of time rangers spend on the job it can be difficult for them to exercise their right to organize more research is needed to understand the accessibility of unions to rangers and the means by which unions can better empower rangers to negotiate for better working conditions effective unions may be able to increase rangers participation in workrelated decisionmaking and advocate for improved working conditions including the conversion of temporary to permanent contracts work accommodation standards payment for working overtime and training opportunities lack of regulatory support nine studies described a lack of regulatory support for rangers though there are numerous policies and laws in most countries to provide regulatory protection for workers in general researchers found that these are often not applied or enforced in the context of rangers as described in one study the local labour department rarely conducted inspections and employers avoided disputes about contracts overtime or salaries by simply not showing up to meetings this is contrary to the ilos labour inspection convention wildlife fund 2019 however a survey of ranger working conditions conducted in 14 ilo member countries identified that most countries had not ratified numerous important ilo conventions lack of workplace rights lack of equipment and training opportunities a lack of workplace rights for rangers was discussed in 44 of the papers one of the most common conditions of precarious employment that emerged from the literature is the lack of sufficient equipment and training opportunities for rangers to safely and effectively perform their required duties rangers do not always have access to necessary protective gear binoculars rations first aid kits or communication devices ogunjinmi et al found that 98 of rangers surveyed felt that patrol equipment including fuel for vehicles was inadequate or in poor condition in addition a global survey by singh et al found that the majority of rangers did not feel they were provided with proper equipment or amenities such as mosquito nets and repellent boots tents compasses gps technology clean drinking water flushing toilets and bedding facilities therefore the right to be protected from danger by having access to needed equipment is not being met in many locations globally rangers can even struggle to obtain the proper uniforms for their job and many rangers have to buy their own equipment with their own money which as previously discussed is problematic given the severe income inadequacy of rangers finally rangers who are not provided with adequate personal protective equipment and come into close contact with wildlife are at high risk of contracting insectborne or zoonotic diseases such as covid19 while basic job training may be provided for rangers such as physical patrol activities some rangers reportedly do not receive any training for the job at all even basic patrol training is insufficient in situations where rangers commonly work with local communities on the human dimensions of wildlife management furthermore although wildlife and forestry training is important training on ranger ethics and duties to the public are often forgotten and rangers do not typically receive training for specialised tasks that are still important aspects of their role such as intelligence gathering engaging communities and the social aspects of dealing with hwc insufficient training can also be directly harmful to the physical health of rangers such as when rangers are not trained in first aid infection control or to understand and respond to heat stress and strain rangers may not be trained in basic unarmed selfdefence and effective arrest techniques similarly rangers are often not supplied with lessharmful gear to handle confrontations with offenders such as batons handcuffs tasers and eye irritants the high risks of the job due to inadequate training and equipment are amplified by the fact that few receive fair insurance in short the insufficient equipment and training of rangers can lead to failed operations serious injuries and death discrimination and harassment while discrimination and harassment are acknowledged within several definitions of precarious employment but not all their inclusion can provide valuable insights the discriminatory treatment of rangers in lowand highincome countries alike may be rooted in systems of racialethnic and genderbased inequalities for example thakholi described numerous ways in which rangers in south africa have experienced racially discriminatory treatment at work while gilpin investigated the longstanding culture of machismo which translates to a hostile work environment for women in the united states national park service rangers may be particularly vulnerable to workplace discrimination given the numerous compounding precarious employment conditions discussed already in addition to their geographic isolation employers of rangers may reinforce inequalities on the basis of race age sex religion sexuality and nationality by allowing the differential treatment of employees in terms of income level conduct verbal and physical harassment opportunities for advancement and unwanted sexual advances between 13 and 15 of rangers surveyed in wwfs 2019 global survey reported having experienced verbal abuse bullying and harassment from coworkers and supervisors while on duty many female rangers across the united states have experienced on the job sexual harassment and assault while the majority of male rangers surveyed in yankari game reserve reported often being mistreated by supervisors our results suggest that rangers do not have sufficient mechanisms in place nor is workplace legislation enforced sufficiently to protect them when they are mistreated on the job in addition rangers clearly lack sufficient whistleblower protection protocols as nearly 60 felt they would be concerned for their safety if they reported corruption in the workplace furthermore the increased masculinization of ranger work gendersegregation of roles and inadequate assessment of womens needs in terms of working conditions and provisions are also among the structural barriers inhibiting gender balance in the ranger workforce unjustifiable dismissal job insecurity and a lack of workplace rights and trust is commonly reported in the literature rangers may fear wrongful dismissal if they make a mistake on the job in some cases rangers have to face stereotyping prejudice discrimination and possible unjustifiable dismissal as their superiors may treat them with suspicion if they come from a community with high levels of illegal wildlife activities as a result of this toxic mistrust some organisations are frequently subjecting rangers to taking polygraph tests during a lengthy controversy in the early 2000s in which parks canada rangers advocated for the right to carry sidearms to protect themselves while performing law enforcement duties the issue became so sensitive that rangers reportedly feared losing their jobs if they spoke up or being transferred to an undesirable remote station these challenges associated with a lack of workplace rights in addition to the low and volatile funding of parks organisations has meant that many rangers around the world experience a high sense of job insecurity the high job insecurity of rangers has been evidenced by the number of rangers who have lost their jobs since the start of the covid19 pandemic as reported by singh et al nearly 20 of rangers reported that colleagues had been laid off from their jobs due to covid19 related budget cuts more than a third of all rangers in central america and caribbean countries reported being laid off closely followed by south america and africa in asia the figure was one in five and in europe less than one in ten 3344 accommodation and living conditions although living conditions are not typically discussed in the context of employment conditions they are an important consideration since many rangers live in accommodations provided by their employers in remote stations in protected areas with no other housing options ranger outposts often lack basic infrastructure to adequately support and accommodate the field rangers for example prior to a recent intervention rangers in bwindi mgahinga conservation area did not have access to decent housing and flush toilets similarly quiçama national park rangers have slept on the ground in metal huts and russian nature reserves can also lack necessary facilities for rangers and some may not even have offices living conditions for rangers can be old dilapidated and highly inequitable even within the same protected area for instance moreto found that while some outposts had fully serviced units others were simple mud or uniport huts and often without access to utilities amenities or clean water ranger outpost structures can be uncomfortably small have leaky roofs and have holes in the walls that invite insects and snakes these often poor ranger accommodation conditions have been exacerbated by the covid19 pandemic as travel restrictions have made it more difficult for suppliers to travel to remote stations and restock food supplies private sector tour operators that previously assisted rangers with patrol rations fuel and vehicle services have reduced or stopped their support working conditions 3351 long working hours and demand for overtime eleven papers indicated that rangers across all geographic regions work extremely long days and nights the global average of working hours of rangers is 72 h per week with 33 of those hours worked at night between the hours of 6 pm and 6am the majority of rangers often have to work overtime and most are not compensated for their overtime hours this trend is particularly notable in south asia and africa rangers also often have to sacrifice sleep during night patrols the overtime demands of the job and the feeling of always being on the job have been linked to high workrelated stress levels in rangers extended patrol trips are also made more precarious given the lack of equipment transport communication devices and the added challenge of making camp and finding water hazardous social and physical work environment violence the most frequently reported dimension of precarious employment of rangers is the hazardous social and physical work environment we found this topic discussed in 74 of the papers reviewed focusing on lowand highincome countries alike many studies stressed that rangers generally face a violent work environment as they are potentially faced with armed poaching logging and fishing gangs who may attack rangers preemptively or in retaliation to ranger actions in addition to armed environmental crime offenders rangers may frequently have to deal with drug cartels that operate within protected areas people who commit violent offences such as homicides and rape and nonstate militias and rebel groups and often do so while working in isolation with no backup wildlife crime is increasingly reported to converge with other types of serious and organised crime activities thus further exacerbating the precarity of ranger work as a result rangers are commonly victims of assault murder vandalism of property or home arson as well as threats and violence directed towards their families for instance an indonesian ranger reported been assaulted by poachers on multiple occasions and having his family house burned down due to his efforts to stop illegal encroachment these threats are intensified for rangers working in locations with political instability and armed conflict for example in garamba national park rangers have historically had to become a heavily militarised force to protect wildlife as they had to prevent illegal resource extraction from opponents with assault rifles beltfed machine guns and rocketpropelled grenades these opponents have in some cases been part of corrupt state militaries nonstate armed groups and wellequipped elephant poachers and cattle herders similarly coca cultivation drug trafficking illegal gold mining illegal logging and illegal wildlife hunting in colombia has attracted at least 17 armed groups to the countrys national parks all enhancing the threat posed to rangers we recognise that the overmilitarisation of the ranger workforce can exacerbate inequalities in marginalised rural communities and increase the risk factors for wildlife crime and instead stress the importance of reducing the precarity of ranger employment while improving communityranger relations environmental factors although environmental factors are not commonly included in research on employment conditions they are an important consideration since many rangers face dangerous encounters with wildlife additionally rangers have to conduct foot patrols over large areas of challenging terrain and with limited access to water and they may work in a wide variety of vast rugged landscapes and outdoors in the rain lightning snow and high winds furthermore support and backup from other rangers other law enforcement services and emergency medical care can be hours away and to worsen matters many rangers lack any access to communication devices during patrols which increases the already high risks of the job working in remote areas and often alone without the ability to communicate leads to many occupational risks for rangers many have died in motor vehicle accidents animal attacks drownings while fighting forest fires and several of them succumbed to the covid19 virus the lack of communication is a particularly urgent concern in south asia where roughly half of rangers surveyed reported never having access to communication devices in addition to wildlife weather terrain and isolation rangers are at high risk of contracting vectorborne waterborne and zoonotic diseases how does precarious employment impact the mental and physical health of rangers mental health given the countless risks and dangers involved in being a ranger as well as the threats to rangers families fellow rangers local community members and to the wildlife that rangers seek to protect it is not surprising that many rangers experience traumatic events throughout their careers despite this we found only 8 papers that discuss the impact of employment conditions and exposures on the mental health of rangers posttraumatic stress disorder acute stress disorder and burnout fatigue have all been mentioned in the literature as a likely reality for many rangers as described in a recent study at home and unarmed antipoaching units and rangers spoke about a persistent sense of anxiety over their safety at work they felt safe but constantly worried about their familys safety other risk factors for the development of mental health outcomes in rangers are occupational stress and emotional strain as a result of being away from their families parents in particular may feel chronic stress for being away from their children for prolonged periods of time with limited leave though the distressing and violent incidents that rangers deal with on the job are wellknown more research is needed to understand how this can impact rangers mental health how to prevent mitigate mental health impacts particularly with regards to trauma and how best to support rangers who have developed mental illness and disorders as a result of their work physical health the previously discussed temperature extremes mean that rangers can experience heat stress and heatrelated symptoms from performing high physical workloads in high temperatures heat stress is particularly challenging for rangers working in areas where it is difficult to access clean drinking water injury and illness due to prolonged exposure to cold temperatures is also likely a challenge for rangers working in cold climates although we did not find any studies that discussed this the inadequacy of housing general lack of equipment such as mosquito nets and often complete lack of shelter while on patrol leaves rangers around the world highly susceptible to fleaborne mosquitoborne tickborne and fly borne diseases in a case study by nagy et al researchers ran a series of diagnostic tests and medical treatments for a 25yearold ranger in romania who was experiencing abnormalities of behavior anxiety visual hallucinations choreiform and facial tics they determined that the ranger had a severe case of exposure to borrelia as a result of tickbites which are a common occupational risk factors for rangers rangers are at high risk of contracting lyme disease dengue malaria african trypanosomiasis and covid19 to name a few studies show that 68 of african rangers surveyed and up to 80 of forest rangers in vietnams bu gia map national park may contract malaria yearly the poor sanitation of ranger stations such as a lack of toilets and sinks and limited access to clean water is an added risk for the transmission of numerous other infectious diseases in addition rangers are susceptible to direct transmission of zoonotic diseases transmission can occur through animal bites or through contact with live animals carcases bodily fluids and feces this is also a risk for rangers when confiscating illegally caught wild animals fifty six percent of rangers surveyed in the great smoky mountains and rocky mountain national parks particularly those working in law enforcement and rescue reported contact with animals at work stevenson et al reported a medical case study of a 28yearold female ranger in australia who began experiencing nausea vomiting anorexia and generalised abdominal discomfort fever respiratory failure and other symptoms her work included park maintenance including disposing of roadkill animals which were mostly kangaroos and wallabies she was diagnosed with q fever which the authors suggested is likely from the frequent ongoing physical contact with dead wild animals in the course of her work the numerous risks of injury and illnesses are compounded by the fact that as previously discussed many rangers may not have access to sufficient or any insurance to cover medical treatments occupational injuries given the challenging social and physical work environment rangers may experience injuries such as broken bones and other serious bodily injuries or even death regarding assault on the job forsyth and forsyth reported that rangers have been shot at and missed…shot at and hit…run over with boats and cars… beat up with fists pipes tree branches pieces of lumber and any other thing someone can pick up grab and swing the lack of first aid kits and training and the inability to get fast medical treatment following injuries may result in otherwise treatable injuries causing irreversible damage or death sixty papers in our study outlined assault and death as two clear consequences of rangers hazardous work environment for example rangers in cambodia have been killed in their sleep by illegal loggers while 13 rangers 1 3 were killed by elephants in 2020 we identified many other similar stories from numerous countries in fact according to the thin green line foundation over 1000 rangers have died protecting wildlife in the past decade and with the escalating risks roughly 150 rangers are currently being killed each year the reported global breakdown of recorded ranger deaths by region from 20092019 were 48 in asia 37 in africa 6 in north america 4 in south america 3 europe 1 in central america and 1 in oceania india has had the highest recorded number of ranger fatalities on duty over the last few years with 46 ranger deaths in 2020 in general causes of workrelated death of rangers have included tetanus falling boulders and trees helicopter crashes motorcycle and automobile accidents vehicular assault heart attacks gunshots rapid changes in weather exposure infection and accidents while operating heavy machinery clearing snow and repairing trails a survey of rangers in asia africa and latin america found that the majority had experienced a lifethreatening situation while on the job especially dangerous encounters with wildlife as well as being threatened by poachers or community members and about 40 had been attacked by poachers in the united states rangers reportedly experience more assaults than officers of the federal bureau of investigation the bureau of alcohol tobacco firearms and explosives and the drug enforcement administration wellbeing twentythree papers discussed the compounding effect of a lack of social support andor supportive relationships and the negative impacts of employment precarity on rangers wellbeing in particular emphasis was placed on how limited time with friends and family impacted rangers wellbeing the inadequate living conditions for rangers along with the distance of ranger outposts from schools and public amenities means that most rangers cannot bring their families to live with them some rangers report being stationed at antipoaching camps for at least 26 days per month which means they can only spend a maximum of 4 days with their family seventy seven percent of rangers surveyed in africa 76 in asia and 53 in central america see their families fewer than 10 days a month in extreme cases rangers may be isolated from their families for an entire year when rangers are transferred to protected area stations that are farther away from their home and families they can perceive these decisions as punishment from management covid19 lockdowns and travel restrictions have worsened the social isolation of rangers and their abilities to see their families rangers may suffer from social alienation isolation and work conditions that harm wellbeing many rangers suffer from poor worklife balance and often report that they feel like they are always on the job the remoteness of ranger work means they have limited leisure opportunities and no respite from the workplace the lack of decent housing and low wages for rangers also likely harms ranger wellbeing female rangers described worklife balance as being particularly challenging during the covid19 pandemic they also reported additional adverse workrelated impacts on their wellbeing such as feelings of anxiety feeling trapped being ostracized receiving hostility from coworkers and supervisors and poor job evaluations after reporting incidents of sexual harassment discrimination rangers may feel alienation lack a sense of belonging and have a lack of access to social interaction these factors of social deprivation are especially prevalent in areas where local communities are opposed to conservation efforts and may treat rangers with hostility in one study roughly 31 of surveyed rangers reported being subjected to verbal abuse bullying harassment and threats from community members while on duty in the previous 12 months in some cases a strained relationship between rangers and the community can directly harm ranger health and wellbeing as rangers often depend on the local communities for basic needs like water rangers may also feel that there is mutual mistrust with community members and fear reprisals for the activities of their job in addition the isolation and lack of social support while on the job is likely to amplify the feelings of fear that rangers feel what are the consequences of not improving the employment conditions of rangers increased risk for rangers to engage in corruption the presence of corruption among rangers was mentioned in 10 papers income inadequacy was repeatedly cited as one of the main drivers encouraging ranger participation in corruption through accepting bribes from poachers in a 2015 paper by moreto et al one ranger explained that since the salary is not adequate he could be tempted to receive that bribe to finish my problems at home while another ranger stated if i kill a buffalo my children can go to school a report by the international union for conservation of nature compared rangers workrelated revenues with the overall profitability of the illegal wildlife trade industry for example assuming a ranger earns us 50 a month an average tenkilo tusk comes in at us 17000 or 340 times that monthly salary rangers expressed that bribe money was put towards necessities such as bills and their childrens school fees and that participation in corruption was done to sustain their welfare a lack of training on the content of rules and regulations limited supervision and the extended periods of time that rangers spend alone at ranger outposts are additional factors contributing to corruption rangers may take advantage of low levels of supervision to form agreements with poachers and intruders in burkina faso an arrangement consisted of rangers allowing herders to graze in restricted areas for a period of time and to then warn them of approaching resource managers in exchange for some sort of payment thus creating a new source of income for the rangers corruption was also linked to contributing factors such as low morale limited motivation and feelings of unfair treatment the risk of corruption may further increase through resentment linked to perceived unfairness which may also negatively impact ranger work efforts one ranger commented that if rangers are not motivated they will start misbehaving looking for money for motivation keeping morale and motivation high can be difficult when every level of a rangers organization may be susceptible to corruption thus undermining good governance and the efforts made by rangers to protect both wildlife and communities corruption can exist at any point in the wildlife crime value chain and can involve and impact rangers prosecutors communities park administrators and other actors for instance some rangers in the drc reported feeling unsafe while conducting their duties due to the risk of detainment or revenge from arrested individuals and acknowledged their willingness to accept bribes instead protecting wildlife and communities is especially challenging for rangers when the government is working against them in cambodia two wildlife rangers lost their life fulfilling their government mandate to defend protected areas even though they were fighting against statefacilitated illegal logging with little incentive to report corrupt behaviour and weak judiciaries leading to low conviction rates for wildlife criminals opportunities for corruption may not be uncommon in contrast to the wealth of evidence that corruption can commonly occur throughout ranger organizations reporting on corruption and misconduct is not a frequent occurrence in a global survey over 50 of rangers agreed they would be concerned for their safety if they reported another ranger for corrupt and illegal activities this is a concerning finding as the fear to speak up allows corruption to grow as a culture within ranger organizations organisations must seek to conduct risk assessments for ranger corruption and develop sound protocols to protect informants and whistleblowers so that they can safely report corruption without fear of retaliation biodiversity protection we found 19 papers that mentioned the precarious employment conditions of rangers as impacting their ability to address wildlife crime or wildlifehuman conflict the geographic distribution of these papers was largely centered on the african region including tanzania drc nigeria and zimbabwe among others the remainder of the papers were global or focused on the southeast asian region the americas and the western pacific none of the included papers focused on ranger employment conditions and species protection in the eastern mediterranean or european regions many of the same factors that contribute to corruption in ranger organizations also inhibit rangers capacity to reduce wildlife crime and hwc including low pay understaffing and harsh working conditions the inadequacy of rangers salaries and their inability to access the necessary equipment for their job may lead disgruntled rangers to apply their expertise to committing wildlife crime or ignoring it rather than preventing wildlife crime research in nigeria has shown that poor working conditions and a salary that is not commensurate with the hazards of the job has incentivised some rangers to relax on the job allow poachers to enter and to get involved in illegal hunting and fishing inflexible work hours and a lack of leave benefits was also considered a barrier for rangers to effectively do their job and prevent or respond to wildlife crime in addition the excessive work hours and workrelated emotional distress can lead to burnout which limits productivity several papers cited adequate training living conditions financial compensation and judicial processes and support as factors that could positively influence the success of a ranger guard force and their capacity to prevent wildlife crime unfortunately budget cuts due to loss of tourism revenue due to covid19 have negatively affected rangers ability to engage communities perform wildlife law enforcement activities and address hwc reductions in ecotourism can also increase wildlife crime as a reduction of tourist presence has contributed to a widening gap in oversight although many illegal hunters may be involved in wildlife crime as a result of multidimensional poverty social inequity and historical injustices rangers in some areas often face members of sophisticated transnational wildlife trafficking networks the persistent lack of ranger training and equipment is especially harmful when while on patrols rangers encounter organised crime groups who possess advanced equipment and technologies in short improving the welfare and employment conditions of rangers and decreasing their precarity generally will contribute to efforts to mitigate wildlife crime and hwc what can be done to improve the employment conditions of rangers half of the papers offered solutions and ideas for interventions that could improve the employment conditions of rangers of these 24 described interventions already implemented in some regions while the remaining 25 provided suggestions and recommendations for additional possible solutions all key interventions mentioned in the literature are included in table 1 overall the majority of the implemented or suggested interventions addressed the following two dimensions of precarious employment conditions concerning rangers lack of rights and protection and working conditions only a handful of studies targeted employment insecurity and income inadequacy several studies discussed solutions that could indirectly improve rangers working conditions through addressing corruption improving community relations and gathering research evidence to document the extent and impact of precarious employment overall the publications which focused on implemented interventions did not discuss the outcomes of the suggested interventions which should be a key consideration for employers searching for suitable solutions additionally the findings suggest that the majority of interventions both implemented and suggested lack a structured approach that would systematically address multiple dimensions of precarious employment including employment insecurity income insufficiency lack of rights and protection in the employment relation and problematic working conditions as evidenced by the dearth of structured highlevel interventions mentioned in the literature we reviewed there is an alarming lack of recognition by governments around the world of the importance of rangers work their key contributions to society the diversity of roles they fulfill and the lifethreatening hazards involved in the profession given that rangers face numerous risks in order to protect biodiversity local communities and park visitors state governments should allocate more resources and invest more in improving ranger working conditions and professionalising the ranger sector to the same extent as some of the more wellrecognised public employees the recognition of rangers as essential workers alongside police border officials firefighters military health and emergency response workers would ensure the provision of essential equipment for rangers the same way that is done for other workers recognized as essential this recognition would also mean that rangers do not have to rely on donations and support from community members and nongovernmental organisations it is also imperative that relevant initiatives are adopted so that the workplace culture in parks and protected areas is made safe for all employees regardless of ethnicity age gender class or any other demographic characteristics particularly given the severity of stresses and dangers that are inherent in this profession thus states should seek to improve and unify their antidiscrimination legal frameworks in accordance with ilos discrimination convention while wildlife authorities and environmental agencies should seek to enforce such legislation in their own organisations efforts to protect wildlife and preserve biodiversity may be futile without a strong legal foundation to protect rangers furthermore although several countries have designated funding from stimulus packages to support protected areas and natural capital in the aftermath of the covid19 given the current pandemicrelated struggles experienced by rangers across the world it is imperative that all rangers receive the support they need research gaps and implications through our scoping review we were able to identify several research gaps that should be addressed to respond to the complexity of rangers employment and working conditions including occupational health issues firstly the examination of relevant publications confirmed that the construct of precarious employment is very rarely used in relation to rangers which could preclude an understanding of the ways in which precarious employment conditions affect workers not surprisingly the examination of rangers health and overall welfare in isolation from their employment and working conditions could also make it difficult to design solutions that target the source of problems not only their symptoms in addition even when several aspects related to various dimensions of precarious employment are partially examined in ranger research studies they are only rarely conceptualized together which makes the accurate study of rangers exposures to employment conditions and the related health outcomes quite challenging if not impossible in recent decades the precarious employment framework has been applied with different population subgroups including the youth migrants women and people with disabilities and various economic sectors including agriculture service sectors and health care often taking advantage of large population and labour market registries as a result there is a large body of literature available should conservation criminological and environmental sustainability researchers focused on rangers become interested in applying this framework secondly although the use of the precarious employment construct would be a good start an expanded theoretical framework that builds on it is needed to account for the intricacy of employment arrangements and occupational health issues identified by this review such an expanded framework could also borrow from or build on the frameworks developed by several major international organizations preoccupied with the health and wellbeing of workers for instance the european foundation for the improvement of living and working conditions uses the job quality framework which is based on seven indices addressing different dimension of job quality including physical and social environment intensity and quality of the work skills and discretion opportunities and earnings further ilo uses the decent work approach which incorporates workers aspirations for productive work and fair incomes workplace security social protections improved opportunities for personal development freedoms of opinion and association and equal treatment for all an acknowledged limitation of this framework is that is too broad and difficult to measure at a global level other frameworks exist and while there are many similarities and differences among such frameworks they have the shared goal of improving job quality for workers and could be explored by researchers interested in examining various aspects of rangers employment thirdly we identified a few specific research topics related to rangers employment that would benefit from further exploration for instance although it has gained attention in recent years research examining the effect of chronic understaffing underfunding and lack of adequate equipment on rangers work and their health and wellbeing should be expanded this is especially important since most wildlife agencies lack the funding necessary to employ an optimal number of rangers for example the orkhon valley national park in mongolia provides an extreme example where just seven rangers are hired to cover 364538 hectares which means that each ranger is responsible for protecting roughly 52000 hectares using horses as the primary mode of transportation as previously emphasised the limited number of staff presents an added danger when rangers encounter nonstate armed groups and poaching gangs which can often outnumber the rangers closely related the effectiveness of solutions that can solve this issue such as poachers to protectors initiatives should be closely examined furthermore although limited research has been conducted to date to understand ranger workplace discrimination findings from existing studies are alarming signaling that this topic warrants more research attention few papers focus on the various marginalised groups that make up the ranger workforce globally fewer than 11 of the ranger workforce are women and 99 of our included studies focused on men it is important that future studies seek to understand how the precarious employment conditions of rangers may differ based on existing inequalities including racial and gender disparities and how best to address these inequalities in addition despite including climate security in our methods as a topic for data extraction we found only isolated mentions of the important role that rangers play in mitigating adverse climatic impacts on communities and wildlife similarly we intended to extract data on the effects of ranger employment conditions on population health however found limited data to draw from the available evidence suggests that rangers who are not adequately housed trained and equipped may either contract infectious diseases which could in turn affect the broader population or be unable to prevent illegal activities that drive zoonotic disease emergence in addition since four out of five rangers surveyed acknowledged the key role they play in controlling the spread of zoonotic diseases through wildlife conservation education and outreach with communities and park visitors more research is needed to understand the specific ways in which rangers can be better supported to mitigate both climate and public health threats lastly the majority of publications on the precarious employment conditions of rangers stems from grey literature reports with limited peerreviewed empirical research future peerreviewed studies could also seek to understand the employment conditions of rangers who are not employed by governments such as indigenous rangers community scouts and rangers in the ngos or private sector specific regions such as central and south america could also be the focus of future studies and metaanalyses that are inclusive of nonenglish publications to learn from the successes and ongoing challenges for improving ranger working and employment conditions in those regions limitations despite our best efforts to conduct a thorough search and analysis of the literature focused on the precarious employment and working conditions of rangers we acknowledge that some potentially relevant papers and sources may have been missed this could be due to limiting our search for practical reasons to english language publications which as a result rendered publications from certain ranger organisations or geographic regions ineligible for inclusion in our study in addition not all of the websites belonging to relevant organisations had interfaces or archives that could be searched limiting our ability to search for publications by key words there may also have been grey literature that was inaccessible as older websites recreated or deleted content refreshing and removing older papers that may have been relevant to our review these limitations to our study impacted the range of papers we were able to include but were unavoidable and in our opinion did not impact the reliability of the papers that were included or the outcomes of our study another limitation is the inadvertent loss of detail and richness of data arising from our attempt to summarize information across numerous studies topics and regions conclusion our results clearly indicate that the majority of rangers currently practicing across multiple geographic regions experience various degrees of employment insecurity income inadequacy lack of workplace rights and protections problematic working conditions and several complex occupational health issues as established through strong evidence precarious employment conditions can be detrimental to workers safety mental health physical health and overall wellbeing given the wide range and complexity of employment arrangements and contextual factors that could affect rangers health and wellbeing the study of employment exposures and the outcomes they have on rangers requires a systematic and consistent approach that uses recognised theoretical frameworks and measures for this reason a theoretical approach that builds on established conceptualizations of the precarious employment construct and other related concepts should be developed the adoption of such an approach would facilitate a better understanding of the complex effects of employment and working conditions as well as the adoption of relevant and sustainable solutions in the shorter term ranger recognition by governments as essential workers alongside police border officials firefighters military health and emergency response workers would facilitate their access to more secure funding and resources we hope that the approach we used in this scoping review to structure the precarious employment domains and related themes along with the concrete findings will spearhead further research on rangerrelated employment and working conditions topics and trigger interest in applying similar lenses many of the issues rangers work to address such as wildlife crimes are complex and can stem from historical injustices and enduring structural issues therefore while addressing the precarious employment of rangers will not singlehandedly solve these issues it is an essential next step improving the employment and working conditions of rangers has implications that extend beyond rangers to affect broader society supporting rangers by improving their access to secure fulltime and permanent contracts adequate income workplace rights and workplace protections along with addressing the whole range of other complex employment and occupational health issues they face will facilitate ongoing attempts to protect natural resources support communities neighbouring protected areas and ultimately advance global biodiversity conservation efforts availability of data and material not applicable code availability not applicable consent to participate not applicable consent for publication not applicable

protecting wildlife and other natural resources requires engaging and empowering local communities ensuring compliance with rules and ongoing monitoring and research at the frontline of these efforts are rangers despite their critical role in maintaining the integrity of parks and protected areas rangers across the world are exposed to precarious employment conditions and hazardous work environments we conducted an international scoping review to understand which employment and working conditions are examined in the context of the ranger occupation and to assess whether the concept of precarious employment is used in the conservation criminological and environmental sustainability literature on rangers we reviewed publications from web of knowledge scopus proquest and medline and grey literature for relevant english language articles published between 2000 and 2021 our findings are based on the analysis of 98 included studies we found that the most commonly discussed aspect of rangers employment and working conditions was the hazardous social and physical work environment although this was often accompanied by severe income inadequacy employment insecurity and a lack of social security regulatory support and workplace rights such employment and working conditions can cause adverse impacts on rangers mental and physical health wellbeing and safety and are also detrimental to their ability to adequately protect biodiversity we conclude by outlining the need for sustainable solutions and additional research based on established conceptualizations of the precarious employment concept and other related concepts lastly we suggest that governments should acknowledge the importance of rangers through their recognition as essential workers and provide greater support to improve their employment conditions

introduction intimate partner violence and abuse defined as the physical emotionalpsychological or sexual abuse by a current or former partner is associated with acute shortterm effects such as injury and poor long term physical and mental health such as obesity and depression 12 as well as substantial social and economic costs 3 public health approaches that can support individuals at high risk for ipva to prevent its occurrence or mitigate its adverse effects are needed and have increasingly become a focus of the uk government 4 adolescence and young adulthood is a time when most individuals establish their beliefs around peer and dating relationships 5 and as such may be an ideal phase in the life course to identify highrisk individuals for primary prevention 6 according to data from the avon longitudinal study of parents and children a birth cohort established in the early 1990s approximately 37 of young people in the uk have been exposed to ipva victimisation by the time they are 21 years old 7 however which groups of young people in the uk might be at greatest risk of ipva victimisation or perpetration and might most benefit from intervention is currently not well understood 28 most evidence on risk or protective factors come from studies of north american populations which are likely to differ both culturally and in terms of educational social health and judicial systems compared to young people in other countries 8 9 10 11 12 13 14 further most studies of ipva have been in small or unrepresentative samples are of adolescents aged under 18 or older adults are in young girls and women only or investigate risk or protective factors for victimisation but not perpetration 8 9 10 11 12 13 14 there is a clear need for contemporary information from large studies and for a deeper understanding of pathways to ipva with which to inform the development and evaluation of prevention strategies we therefore investigated risk factors for ipva occurring up to age 21 in a large uk populationbased birth cohort the aim was to identify subgroups of adolescents and young adults who are at greatest risk of either ipva victimisation or perpetration methods data we conducted a crosssectional analysis of data from birth to 21 years old on participants from the alspac cohort alspac recruited 14500 pregnant women residing in avon uk with expected delivery dates in april 1991december 1992 and has collected information on the mothers partners and their offspring on a wide range of mental physical economic and social factors for the subsequent 25 years study data were collected and managed using redcap electronic data capture tools hosted at university of bristol 15 more information on alspac is available within published cohort profiles 16 17 18 the study website contains details of all the data that is available through a fully searchable data dictionary and variable search tool 19 we focussed on participants in the age 21 wave all eligible participants who could be contacted were provided details of an online questionnaire in middecember 2013 and then sent a series of up to four reminders at threeweek intervals some of these reminders containing a paper version of the same questionnaire the dataset for the age 21 wave consisted of 34599353 who had responded the current studys cohort was the 3279 who answered questions within the ipva section data were not available on reasons for noncontact or nonresponse characteristics of study cohort characteristics of the 1149 males and 2130 females in the study cohort have been reported elsewhere 7 in summary the majority of participants were white lived with both parents had a mother that was married and had parents who were both in professional managerial or skilled occupations when they were born by age 16 approximately twothirds defined themselves as 100 heterosexual around half had reported having had at least one ace and around onefifth of girls reported having selfharmed 20 by age 18 around onefifth of girls and boys reported drinking hazardous levels of alcohol or risky sexual behaviour such as not using contraception and one in ten had ever been hospitalised as by definition ipva occurs within intimate relationships we estimated how many of the study cohort had been in a relationship by age 21 through two questions explicitly capturing this at ages 13 and 17 and augmented by responses to other questions at ages 1221 20 this indicated minimum prevalence of relationships that were still likely undercaptured so we did not restrict the analysis according to these questions over half of the study cohort explicitly said that they had been in a relationship by amendments from version 2 this manuscript has been updated to address comments from reviewers 1 and 2 respectively main changes are estimates of risks have been updated it was pointed out that the original estimates were in fact odds ratios we now report relative risks though estimates are all slightly closer to the null compared to in the previous version of the manuscript general conclusions about the strongest riskprotective factors havent changed we make clear that we could not explore differences in ipva patterns between longterm relationships and onenight stands we give a clearer definition of how deprivation was measured and that the index of multiple deprivation is a socioeconomic indicator we provide more discussion around gender identity and sexual orientation and its importance in being explored in future qualitative work we also discuss implications of high proportions of missing sexual orientation within the data any further responses from the reviewers can be found at the end of the article age 18 and 74 indicated this increasing to 88 by the time they were 21 these proportions were similar between men and women young people were less likely to report being in a relationship by age 21 if they were nonwhite with little difference between those of different deprivation categories or sexual orientation exposures we investigated individual relational and community characteristics as potential risk factors based on previous literature 8 9 10 11 12 13 14 these factors were high arealevel deprivation ethnic minority status sexual minority status we also investigated 11 different types of adverse childhood experiences 22 further details on how these variables were derived are provided in extended data table b 20 for most exposures we imputed any missing values using multiple imputation via chained equations we assumed values to be missing at random and sufficient auxiliary information with which to impute except for ethnicity sexual orientation risky sexual behaviour and hospitalisation we also included imputed ace variables as previously described 22 further details on imputation methods used are provided in extended data box a 20 outcome ipva the ipva section of the questionnaire at age 21 was based on previous uk and european questionnaires and the provide questionnaire 2324 and is described in full in a paper validating its psychometric properties 7 questions asked about occurrence of eight different examples of emotional physical and sexual ipva victimisation within intimate relationships including onenight stands the questionnaire did not distinguish between the lengthtype of relationship as in previous research from our group relationships for young people are more difficult to categorise than for older adults 2325 participants were also asked the frequency of these events and whether they occurred beforeafter turning 18 or both periods there were also four similarly worded questions on occurrence and frequency of emotional physical and sexual ipva perpetration participants were also asked how did you feel after they did these things to you following the batch of victimisation questions with ten different response options for the purpose of this study we considered a participant to have experienced ipva victimisation perpetration and their different types if they had responded at least once for any of the respective questions it has been previously argued that thresholds should be carefully considered for certain types such as emotional victimisation to avoid overestimating ipva 26 we defined the cutoff never vs ever for two reasons firstly the header of the questionnaire was intimate partner violence likely raising the threshold of severity for reporting certain behaviours secondly for participants who answered ever to any of the eight different victimisation questions ie including those relating to emotional ipva negative impact was reported by 7599 statistical analyses we estimated the prevalence of ipva victimisation and perpetration respectively up to age 17 at age 1821 and ever overall and by each factor of interest among those reporting any ipva victimisation we reported the proportions who reported negative neutral or positive impact we then presented the association between each of the factors of interest with ever ipva victimisation and perpetration respectively as risk ratios and 95 confidence intervals these risk ratios were approximated from estimated odds ratios as per zhang et al 27 we stratified all analyses by sex given that a large part of the literature focuses on violence against girls and women 91228 and to allow comparison with previous reports there were insufficient data to also incorporate gender in analyses again for comparability with previous work we present prevalence of ipva types ie emotional physical and sexual ipva respectively in the main text of this report we present results on exposures where missing values have been imputed the same results for completely observed exposures are presented in extended data table f 20 we analysed all data in stata version 151 except for multiple imputation which was carried out in r version 353 as per disclosure rules for use of alspac data we do not report any numbers less than 5 the r script used for analyses is available at ipva consent and ethical approval written informed consent was obtained from the parents of participating children after receiving a full explanation of the study children were invited to give assent where appropriate study members have the right to withdraw their consent for elements of the study or from the study entirely at any time full details of the alspac consent procedures are available on the study website the questions on ipva were approved by the alspac ethics and law committee results prevalence of ipva victimisation and perpetration overall 29 of males and 41 of females reported ever being victimised and 20 and 25 reported ever perpetrating ipva 16 and 22 reported both victimisation and perpetration emotional ipva was the most common type present in the majority of victimisation and perpetration reports 14 and 17 of men and women respectively reported experiencing either emotional victimisation or emotional perpetration but no other type ipva victimisation and perpetration were more likely at an older age 263 reported being victimised both before and after turning 18 years old and 130 reported perpetrating during both periods rates of reported physical perpetration were higher in women than in men sexual ipva perpetration was reported by 2 of men and 03 of women impact of ipva victimisation prevalence of victimisation and perpetration by all factors studied and age are presented in extended data tables de over 60 who reported any ipva victimisation also reported experiencing a negative impact the most likely impacts were feeling angryannoyed upsetunhappy or sad women were more likely than men to report each of the seven negative types and men were more likely to report any neutral or positive impacts 3 risk factors for victimisation risk factors for perpetration the risk of ipva perpetration was also increased for nearly all factors studied except for ethnic minority status high levels of parental monitoring or neet status at age 20 point estimates for risks of perpetration were also increased for both men and women exposed to aces by age 16 for most categories risks of perpetration by age 21 were highest in men and women who reported engaging in antisocial behaviour at ages 13 or 18 anxiety symptoms at 2 risks were also greater for men who suffered depression symptoms or who had been sexually abused or had witnessed domestic violence by age 16 sensitivity analyses distributions of factors after imputing missing values tended towards greater adversity which is often the case given that more vulnerable young people are more likely to be missing from analyses 29 when we compared results using multiple imputation with those in observed data only findings were very similar the median difference in model coefficients was 6 the largest differences were for deprivation and its association with victimisation in men and neet status at age 18 and its association with perpetration in men discussion in a contemporary uk populationbased cohort almost three out of ten young men and more than four out of ten young women reported having been exposed to ipva by the time they were 21 and one in five men and one in four women reported having perpetrated ipva we show that these risks were increased for men and women as they turned 18 particularly for those who reported selfharm antisocial behaviour regular cannabis or illicit drug use by adolescence men who engaged in risky sexual behaviour had been sexually abused or had witnessed domestic violence and sexual minority women were also at increased risks strengths limitations this study was carried out in a populationbased cohort with a rich range of individual relational and communitylevel variables of interest we used a validated scale to capture ipva victimisation 7 and a novel measure of ipva perpetration the studys longitudinal nature and the fact the participants were asked to state whether the ipva took place before or after turning 18 meant that we could capture characteristics of interest both before and at the time the ipva occurred the accuracy of our estimates of association between different potential risk factors and ipva depends on the accuracy of our measures of these factors and outcome most measures used were chosen from a wider range of measures available for example we used information about selfharm from two of the three waves where this was available at 1017 years old we selected measures based on previous studies using alspac data that have provided estimates of prevalence for these factors that are in line with those reported in the wider literature we further accounted for missingness of exposure values through robust multiple imputation methods in regards to the outcome of ipva we parametrised this as broadly as possible supported by previous work 7 onlinedigital abuse is increasingly prevalent 3031 but the ipva questions did not include any examples of onlinedigital abuse beyond checking up on someone by phone or text therefore we could not study other common examples such as sending sexually explicit images it has also been well documented in the adult literature that ipva can be underreported due to recall or reporting biases particularly perpetration 3233 therefore our estimates of ipva prevalence are likely to provide a conservative estimate of the true prevalence the demographic makeup of those in the alspac cohort limits generalisability of the estimated prevalence of ipva to relatively affluent predominantly white uk populations 16 just over onethird of individuals still in the cohort at 21 years old responded to the age 21 wave internal checks found that those who responded were marginally more likely to be relatively affluent white and extremely parentally monitored and less likely to carry out certain risktaking behaviours previous work around the effects of participation rates in alspac data and norwegian data in young people found that this phenomenon had a small effect on resulting relative risks and odds ratios for these factors 2934 though we have some information about sexual orientation of the cohort the ipva questionnaire did not explicitly ask about the sex of the person who either victimised the individual or that the person victimised at least 8 of men and 9 of women had identified as not being 100 heterosexual at age 15 but there were 25 and 30 for which this information was not available estimated relative risks of not being 100 heterosexual vs 100 heterosexual in data where sexual orientation was imputed were very similar to those estimated in complete case data only therefore estimated effect sizes were negligibly impacted however given the potentially large proportions of participants who identified as not being 100 heterosexual when interpreting sexspecific overall prevalence and relative risks we cannot assume that victimisation outcomes reported by a male will have been perpetrated by a female or vice versa comparison to other literature we found that most of the risk factors for ipva victimisation previously identified in north american young people were also potential risk factors for victimisation in a uk cohort 8 9 10 11 12 13 14 but this was not the case for low socioeconomic status 1135 in the current study there was no clear relationship between areabased deprivation and risks of either victimisation or perpetration this is consistent with findings of two recent uk crosssectional studies one suggesting no relationship between ses and emotional or physical victimisation or perpetration among 1116 year olds 736 the other suggesting no relationship between ses and emotional or online sexual victimisation among 1619 year olds 37 a recent longitudinal study using alspac data estimated that cumulative exposure to low ses was associated with a modest increase in risk of ipva at ages 1821 38 and ipva victimisation frequency low ses may have a relatively modest relationship with exposure to any ipva as ses is a very distal factor this is consistent with analysis based on the crime survey for england and wales 39 reporting a stronger association between low ses with more frequent ipva events relative risks of ipva for individuallevel factors that are closely related with ses did not provide much clear evidence about the relationship between ses and ipva either point estimates for the association between high academic achievement and ipva were negative for victimisation but positive for perpetration neet status at 18 years old had a positive association with both victimisation and perpetration whereas neet status at 20 years old had a negative association the relationship between ses and ipva should still be examined and accounted for in future research the pathways from different ses indicators to and from both ipva victimisation and perpetration need to be explored more closely we found that most factors studied were risk factors for as well as victimisation ipva perpetration particularly anxiety depression selfharm antisocial behaviours cannabis other illicit drug use sexual abuse and witnessing domestic violence this is a novel addition to the literature given the paucity of reporting of risk factors for perpetration implications for policy practice and research the fact that a large minority of young men and women aged up to 21 have been victimised andor perpetrated ipva highlights that the focus of primary and secondary prevention of intimate partner violence and abuse needs to be broadened to include this age group only relatively recently has there been a sustained uk public health focus on ipva in young people in particular 103637 schoolbased intervention for primary prevention of ipva that has shown some promise in north america 4041 is currently being piloted in the uk 42 statistics characterising those at highest risks of exposure to ipva in this age group such as those reported in the current study can inform optimisation of such interventions or future initiatives in similar populations our findings add to the debate around sex differences in violence and whether the dichotomy of female victimisation and male perpetration widely found in north american adult ipva studies similarly applies for uk adolescent and young adults the prevalence of ipva victimisation was indeed higher in females compared to males particularly for physical and sexual victimisation nevertheless the prevalence of victimisation among males was still substantial at around one in four in contrast to the adult literature we found that the prevalence of perpetration was higher in females than males which was similarly the case when broken down into emotional and physical types but not sexual where male perpetration was higher it is possible that the sex differences for relationships of ipva could differ for this younger age group 33 however it must be noted that these sex differences in prevalence could also be partially driven by sex differences in reporting biases 33 and that among those reporting to have been victimised females were more likely to report negative impact than males including impacts that would be likely to have longterm health impacts elsewhere we are currently examining the relationship between ipva and impact in terms of different patterns of types and frequency of ipva and whether this might explain any sex differences 43 future qualitative lifecourse interviews in this agegroup will seek to explore in greater depth these differences from the perspectives of young men and young women who have experienced ipva including how these experiences have impacted on their lives 44 such interviews provide scope to explore other important factors such as gender and sexual identity and their experiences given that ipva is particularly prevalent for minority groups 45 46 47 there is scope for further work in this area to better understand the pathways explaining the associations reported in the current study we did not include potential risk factors simultaneously in a multivariable regression model as is commonly done in similar epidemiological studies as our aim here was to identify risk factors andor characteristics of young people exposed to ipva and not necessarily to quantify associations whilst adjusting for other potential characteristics such an analysis would likely result in overadjustment due to the clustering complex and potentially causal relationships between explanatory variables for example it is well known that mental health problems such as depression or anxiety are heavily linked to risky externalizing behaviours such as substance misuse or antisocial behaviour 4849 factors identified as being associated with ipva in this study can be taken forward to be robustly studied within a causal framework ie based on prehypothesised pathways to ipva 50 we found a plethora of factors associated with an increased risk of ipva therefore our findings provide a focal point for research efforts aimed at elucidating the likely complex pathways to ipva in young people only by understanding such pathways can we improve prevention efforts data availability alspac data access is through a system of managed open access the steps below highlight how to apply for access to alspac data including access to the statar scripts used for analyses reported in this research article 1 please read the alspac access policy which describes the process of accessing the data and samples in detail and outlines the costs associated with doing so 2 you may also find it useful to browse our fully searchable research proposals database which lists all research projects that have been approved since april 2011 3 please submit your research proposal for consideration by the alspac executive committee you will receive a response within 10 working days to advise you whether your proposal has been approved if you have any questions about accessing data please email the alspac data management plan describes in detail the policy regarding data sharing which is through a system of managed open access extended data clare tanton global health and development london school of hygiene and tropical medicine london uk thank you for the response to my previous comments and the changes you have made to the manuscript i have the following additional comments in the response the authors say tables 2 and3 do present relative risks that is the prevalence of ipva at age 021 for one level of the factor the prevalence of ipva at age 021 for the reference level of the factor however in my understanding of these tables this is not the case taking the example the authors give the relative risk would be 303285 for men which is a rr of 106 whereas the table shows a rr of 109 an or however would be 1 the difference is less apparent here but for example for the variable sexual identity the or is 191 but this is not the same as the prevalence almost doubling as the percentages are 40 4 katharina goessmann department of psychology bielefeld university bielefeld germany i appreciate the opportunity to review this important and highquality research manuscript the study provides an interesting descriptive analysis of associations of intimate partner violence victimization and perpetration among uk youth and young adults the study has several strengths such as its longitudinal design and large sample i think the authors addressing of the suggestions from reviewer 1 has already enhanced the manuscript and i only have some minor comments for further improvement method page 4 outcome ipva ipva is defined here as violence performed in partnerships however the instrument used to assess ipva also includes violence that happened during single occasion intimate encounters did you assess whether reported ipva occurred in a relationship or during a onenight stand could you please discuss implications of this inclusion ○ the article is about violence performed in partnerships called intimate partner violence the authors use the abbreviation ipva for this however in their table captures ipva is used short for interpersonal violence and abuse for reasons of consistency i suggest to use the term intimate partner violence and abuse throughout the manuscript instead of interchanging it with interpersonal violence plus the spelling of interpersonalinterpersonal is inconsistent ○ deprivation is introduced in the methods and tables as a potential risk factor for ipva but it is not clear to me what is meant by deprivation which seems to be used here as an ses indicator please consider explaining the term deprivation for nonuk readers ○ the authors state that gender was not included in the analyses due to insufficient data however the authors talk about gender differences in their discussion of results even though only sex was included in the analyses please make sure to use the correct terminology throughout the manuscript also as sexual and gender minority groups are among those most affected by interpersonal and partner violence especially sgm youth and 304 of the sample this prevents further interpretations of the results in terms of gender dynamics in partnerships and should be mentioned in the discussion of gender differences on page 11 the discussion needs to consider the missing information regarding sexgender of the relationship partners in this study as from this data it cannot be concluded that victimization of a male person means perpetration by a female and vice versa a more detailed assessment of perpetrator characteristics relationship types and participants sexual orientation is a potential for future study and should be discussed wording i suggest using the term sexual orientation instead of sexuality the study provides an interesting descriptive analysis of associations of intimate partner violence victimization and perpetration among uk youth and young adults the study has several strengths such as its longitudinal design and large sample i think the authors addressing of the suggestions from reviewer 1 has already enhanced the manuscript and i only have some minor comments for further improvement thank you for your positive response to our work we really appreciate you taking the time to review our manuscript we have tried to address your comments pointbypoint below method page 4 outcome ipva ipva is defined here as violence performed in partnerships however the instrument used to assess ipva also includes violence that happened during single occasion intimate encounters did you assess whether reported ipva occurred in a relationship or during a onenight stand could you please discuss implications of this inclusion 1 although the question asking about ipva experiences states that this can include within either relationships or onenight stands the questionnaire doesnt ask explicitly about whether the experience took place in one or the other this was intentional as relationships for young people and the young peoples own understandingsinterpretations of what it means being in a relationship are more difficult to categorise than for older adults in previous research from our group many young people spoke about more flexible encounters where they knew the other person but also had onenight stands with them and were not exclusive although the lengthtype of a relationship is not necessarily related to the intensity of the relationship experience or to the impact of ipva on young people in our qualitative interviews we use a lifecourse calendar approach which gives more opportunities to reflect on how these factors might relate to ipva experiences we have now included the following text in the methods to make this point was thank you for spotting this inconsistency we have now gone through the manuscript and ensured that the updated version only includes ipva to mean intimate partner violence and abuse there should now no longer be any mention of interpersonal in the main text or extended data 3 deprivation is introduced in the methods and tables as a potential risk factor for ipva but it is not clear to me what is meant by deprivation which seems to be used here as an ses indicator please consider explaining the term deprivation for nonuk readers we 4 the authors state that gender was not included in the analyses due to insufficient data however the authors talk about gender differences in their discussion of results even though only sex was included in the analyses please make sure to use the correct terminology throughout the manuscript also as sexual and gender minority groups are among those most affected by interpersonal and partner violence especially sgm youth whitton et thankyou when we say gender differences we do indeed mean sex differences and this has now been corrected throughout the updated manuscript we discuss sex differences in ipva patterns in the second paragraph of implications for policy practice and research and have now expanded this to include gender identity and sexual orientation was …elsewhere we are currently examining the relationship between ipva and impact in terms of different patterns of subtypes and frequency of ipva and whether this might explain any sex differences future qualitative lifecourse interviews in this agegroup will seek to explore in greater depth these differences from the perspectives of young men and young women who have experienced ipva including how these experiences have impacted on their lives now …impacted on their lives such interviews provide scope to explore other important factors such as gender and sexual identity and their experiences given that ipva is particularly prevalent for minority groups 5 also the sexgender of the victimized or perpetrating partners respectively was not assessed and information on sexual orientation is missing from 245 and 304 of the sample this prevents further interpretations of the results in terms of gender dynamics in partnerships and should be mentioned in the discussion of gender differences on page 11 the discussion needs to consider the missing information regarding sexgender of the relationship partners in this study as from this data it cannot be concluded that victimization of a male person means perpetration by a female and vice versa a more detailed assessment of perpetrator characteristics relationship types and participants sexual orientation is a potential for future study and should be discussed while it is true that information on sexual orientation was missing for around onequarter to onethird of individuals the main results relate to data that were multiply imputed including the sexual orientation variable estimated relative risks from the multiply imputed datasets were similar to those estimated from data on complete cases only ○ it is an important point that for those indicating that they were not 100 heterosexual we cannot say whether the relationshipsonenight stands that these ipva experiences occurred in were oppositeor samesex pairs and the sex of the victim or perpetrator that the individual is answering about we have now included the following text in the discussion under strengths and limitations to make this point though we have some information about sexual orientation of the cohort the ipva questionnaire did not explicitly ask about the sex of the person who either victimised the individual or that the person victimised at least 8 of men and 9 of women had identified as not being 100 heterosexual at age 15 but there were 25 and 30 for which this information was not available estimated relative risks of not being 100 heterosexual vs 100 heterosexual in data where sexual orientation was multiple imputed were very similar to those estimated in complete case data only therefore estimated effect sizes were negligibly impacted however given the potentially large proportions of participants who identify as not being 100 heterosexual when interpreting sexspecific overall prevalence and relative risks we cannot assume that victimisation outcomes reported by a male will have been perpetrated by a female or vice versa we are currently carrying out more detailed assessment of perpetrator characteristics relationship types and participants sexual orientation as part of qualitative lifecourse interviews which we discuss in the second paragraph of implications for policy practice and research 6 wording i suggest using the term sexual orientation instead of sexuality we agree and this has now been done both in the main manuscript text and extended data 7 discussion page 12 as the authors mention the link between mental health and risky externalizing behaviours such as substance misuse or antisocial behavior is well established however the citations provided by the authors albeit interesting are not exactly fitting for this statement in my opinion as they focus more on the link between substance abuse and antisocial behaviors or depression as a mediating variable between sexual orientation and alcohol abuse please consider adding additional references we have now updated these references to 1 wiesner et al j abnormal psych 2003 which directly investigates the bidirectional relationship between depressive symptoms and delinquent behaviour 2 campbell et al prev med 2020 which directly investigates the association between different risky externalizing behaviours and depression and anxiety reviewer report 23 september 2020 © 2020 tanton c this is an open access peer review report distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited clare tanton global health and development london school of hygiene and tropical medicine london uk this is an interesting analysis of ipv data from alspac it builds on earlier work published in this area from the dataset extending this work to look at risk factors for both ipva victimisation and perpetration i have a couple of main comments firstly one of the stated strengths of the study is that it is longitudinal and could capture characteristics before and at the time the ipva occurred i agree with this however i dont think that the analysis and presentation of the results maximises this strength the main outcome used is experience of ipva up to age 21 so it is not possible to disentangle the sequence of events for many of these exposures i wonder whether the authors considered looking at ipva after age 18 and exposures before this time then i wondered whether the results would be better presented by trying to group the exposures by life stage rather than eg grouping together mental health at two different ages thinking through to implications for prevention and at what age this might occur and how to identify those at risk at different stages of development can stronger risk factors be identified earlier in life i appreciate that the authors say in the discussion that they do not want to construct a multivariable model in this analysis but i think the analysis could be presented in a way that is more coherent with this staged approach to data analysis secondly the tables look to present odds ratios rather than relative risks if i am correct the text should be adjusted to reflect that these are odds ratios at the moment it refers in a number of places to a doubling of risk but this is not the case looking at the percentages because the prevalence of ipva is high some additional comments introduction could references be added to the following sentence further most studies of ipva have been in small or unrepresentative samples are of adolescents aged under 18 or older adults are in young girls and women only or investigate risk or protective factors for victimisation but not perpetration methods data could you add the year the age 21 wave was collected i found the description of the sample confusing you state that this is the 3279 answering questions within the ipva section then the next paragraph refers to estimating how many of the cohort had been in a relationship was this to define who answered the questions on ipva the response rate to the survey is not high is there a comparison elsewhere between those who responded and those who didnt to better understand the biases that could be referenced could you include some further information on this in the discussion there are a lot of missing data i have presumed that this is due to noncompletion of previous surveys but a tablefigure summarising who completed which surveys might be useful within the main paper i cannot comment on the methods used to deal with the missing data results figure 1 these results by gender appear in an earlier report of these data where they are compared statistically there are differences reported by gender for almost all negative impactsthese are larger for the negative impacts which may have a longerterm impact eg anxiety depression affecting studies this could be mentioned in the discussion there are a lot of really interesting results presented i wonder if the tables would be easier to follow if they were split by victimisation and perpetration rather than by gender this would help align the text since the comparison being made in the text is by gender rather than by victimisaitonperpetration tables make number of decimal places consistent for percentages i think tables 2 and 3 would benefit from having the no people in each of the categories text states that early all factors studied were positively associated with ipva victimisation by age 21 except for high levels of parental monitoring at age 15 neet status in young men and ethnicity minority status in women which were negatively associated but i didnt see a negative association for ethnic minority status for women discussion the discussion of gender and violence would benefit from further contextualisation of the results by gender eg frequency of occurrence of violence no different items experiencedperpetrated experience of no different types of violence the first paragraph of the results could be expanded along these lines area level deprivation is a limited measure since it does not tell you anything about an individuals ses you could also discuss findings from other proxies eg education and neet status in this section is the work clearly and accurately presented and does it cite the current literature yes 1 firstly one of the stated strengths of the study is that it is longitudinal and could capture characteristics before and at the time the ipva occurred i agree with this however i dont think that the analysis and presentation of the results maximises this strength the main outcome used is experience of ipva up to age 21 so it is not possible to disentangle the sequence of events for many of these exposures i wonder whether the authors considered looking at ipva after age 18 and exposures before this time is we did indeed consider the possibility of exploring ipva at 1821 only for the reasons given in the comment however we decided that as the principal purpose of the study was descriptive and to characterise young relationships in terms of both historical and current sociodemographic parental behavioural and clinical factors that the sequence of events was not a priority relative to being able to describe the range of factors that we did for example hazardous alcohol use and neet status factors which have never been described for young people exposed to ipva in the uk before were only captured at 18 years or older further looking at exposures before turning 18 and outcomes after turning 18 could only interpreted in terms of sequence of events if the sample was further restricted to those who did not report any ipva at age 017 we have started to explore this in other work that looks more deeply at specific variables and their relationships with ipva and attempts to infer causal pathways but feel it is beyond the scope of the current descriptive study for those interested in descriptive statistics of factors for those exposed to ipva at age 1821 in particular these are provided in tables d and e of the extended data file as mentioned in the response to comment 1 the purpose of the study is to describe the cohort rather than disentangle sequences of events in table 2 the outcome is ipva at age 021 and so we feel it is more meaningful to group the factors in these tables according to domain ie demographic internalising behaviours etc we have now included extra labelling in table 2 to make this clear in table 3 factors all relate to the domain of aces and the periods when these factors were captured are all very similar and so we did not alter any ordering here then however in table d of the extended data file the ipva outcome here is separated out by time and so we have reordered the factors chronologically as the reviewer suggests 3 secondly the tables look to present odds ratios rather than relative risks if i am correct the text should be adjusted to reflect that these are odds ratios at the moment it refers in a number of places to a doubling of risk but this is not the case looking at the percentages because the prevalence of ipva is high tables 2 and3 do present relative risks that is the prevalence of ipva at age 021 for one level of the factor the prevalence of ipva at age 021 for the reference level of the factor 4 could references be added to the following sentence further most studies of ipva have been in small or unrepresentative samples are of adolescents aged under 18 or older adults are in young girls and women only or investigate risk or protective factors for victimisation but not perpetration this sentence is supported by the references from the previous sentence we will also include them after the current sentence the cohort is indeed all of those who answered questions in the ipva section regardless of whether they indicated that they had been in a relationship or not we agree that including the paragraph on relationships within the section on data is confusing and we apologise we therefore will move this paragraph into the section characteristics of the study cohort in the next version of the manuscript indeed in this latter section we already describe the proportions who have indicated a relationship by certain ages so it makes more sense that the text should go here 7 the response rate to the survey is not high is there a comparison elsewhere between those who responded and those who didnt to better understand the biases that could be referenced could you include some further information on this in the discussion thankyou for the suggestion we have now extended some of the text that covers external validity and include reference to the description of the full cohort we have changed the following text the demographic makeup of those that responded to the ipva questionnaire limits generalisability of the estimated prevalence of ipva to relatively affluent predominantly white uk populations this should not substantially affect the generalisability of reported associations between a range of risk factors and increased risk of ipva though it is possible that the magnitude of the association might differ to the demographic makeup of those in the alspac cohort limits generalisability of the estimated prevalence of ipva to relatively affluent predominantly white uk populations for these variables it is possible to say if these factors were present but not if they were absent however if we have misunderstood and the comment is asking for other information please let us know and wed be happy to try to provide it 9 figure 1 these results by gender appear in an earlier report of these data where they are compared statistically there are differences reported by gender for almost all negative impactsthese are larger for the negative impacts which may have a longerterm impact eg anxiety depression affecting studies this could be mentioned in the discussion thanks for this suggestion we have updated the following sentence however it must be noted that these gendered differences in prevalence could also be partially driven by gendered differences in reporting biases and that among those reporting to have perpetrated ipva females were more likely to report negative impact than males to however it must be noted that these gendered differences in prevalence could also be partially driven by gendered differences in reporting biases and that among those reporting to have been victimised females were more likely to report negative impact than males including impacts that would be likely to have longterm health impacts we are currently examining the relationship between ipva and impact in terms of different patterns of subtypes and frequency of ipva and whether this might explain any gender differences 10 there are a lot of really interesting results presented i wonder if the tables would be easier to follow if they were split by victimisation and perpetration rather than by gender this would help align the text since the comparison being made in the text is by gender rather than by victimisaitonperpetration thanks for this suggestion which we agree will make interpretation easier we have now updated tables 2 and3 and extended data tables d e and f as such 11 tables make number of decimal places consistent for percentages apologies this has now been done 12 i think tables 2 and 3 would benefit from having the no people in each of the categories tables 2 and3 are of pooled results from multiply imputed data we have now included footnotes to make this clearer numbers of people in each of the categories in the raw data are provided in extended data table c 13 text states that early all factors studied were positively associated with ipva victimisation by age 21 except for high levels of parental monitoring at age 15 neet status in young men and ethnicity minority status in women which were negatively associated but i didnt see a negative association for ethnic minority status for women in table 2 the relative risk of ipva victimisation for ethnicity minority status women was 087 14 the discussion of gender and violence would benefit from further contextualisation of the results by gender eg frequency of occurrence of violence no different items experiencedperpetrated experience of no different types of violence the first paragraph of the results could be expanded along these lines in table 1 we cover the prevalence of different subtypes of ipva victimisation and perpetration these results and the comparison between genders are discussed in the first paragraph of the results section under prevalence and impact of ipva victimisation and perpetration our analysis and results do not touch on other dimensions of ipva such as frequency of occurrence or number of items experiencedperpetrated we are exploring the latter dimensions in a separate study which is in progress 15 area level deprivation is a limited measure since it does not tell you anything about an individuals ses you could also discuss findings from other proxies eg education and neet status in this section we appreciate that point that education and neet status are individuallevel factors that could tell us something about the relationship between ses and ipva in the next version of the manuscript we have updated the paragraph about ses to include the following text relative risks of ipva for individuallevel factors that are closely related with ses did not provide clear evidence about the relationship between ses and ipva either high academic achievement had negligible associations with ipva for men and appeared to have negative associations with ipva for women neet status at 18 years old had a positive association with both victimisation perpetration whereas neet status at 20 years old had a negative association with ipva victimisation and positive association with perpetration the relationship between ses and ipva should still be examined and accounted for in future research the pathways from different ses indicators to and from both ipva victimisation and perpetration need to be explored more closely additionally whilst updating the manuscript in response to the reviewer comments we realised that the exacting wording of the question around impact related only to victimisation therefore we have also updated figure 1 to only include impact outcomes relative to victimisation status not victimisation and perpetration difference is less apparent here but for example for the variable sexual identity the or is 191 but this is not the same as the prevalence almost doubling as the percentages are 404 and 262 the text needs to represent that these are ors rather than rrs having gone back to the original r code used youre absolutely right and indeed we pooled results of logistic regression models across imputed datasets thanks for spotting this and we apologise for the error we have updated the results to reported estimated rrs these changes affect tables 2 and3 since this or is close to one and the 95 ci crosses 1 substantially to me this suggests no evidence for an association between ethnicity and ipva victimisation open peer review competing interests no competing interests were disclosed reviewer expertise violence genderbased violence mental health i confirm that i have read this submission and believe that i have an appropriate level of expertise to confirm that it is of an acceptable scientific standard competing interests no competing interests were disclosed version 1 competing interests we have none to declare author response 07 jan 2021 annie herbert university of bristol bristol uk thank you for the response to my previous comments and the changes you have made to the manuscript thanks clare for taking the time to look over the updated version we have tried to address your outstanding comments below 1 in the response the authors say tables 2 and3 do present relative risks that is the prevalence of ipva at age 021 for one level of the factor the prevalence of ipva at age 021 for the reference level of the factor however in my understanding of these tables this is not the case taking the example the authors give the relative risk would be 303285 for men which is a rr of 106 whereas the table shows a rr of 109 an or however would be 1 the competing interests no competing interests were disclosed

background approximately onethird of young people in the uk have suffered intimate partner violence and abuse ipva on reaching adulthood we need interventions to prevent ipva in this population but there is a lack of evidence on who is at greatest risk methods we analysed questionnaire data from 3279 participants of the avon longitudinal study of parents and children populationbased birth cohort we estimated the prevalence of ipva victimisation and perpetration by age 21 by sex demographic parenting mental health externalising behaviour eg smoking educational employment and adverse childhood factors results overall 29 of males and 41 of females reported ipva victimisation with 20 and 25 reporting perpetration respectively 16 and 22 both the most common type of ipva was emotional followed by physical then sexual history of anxiety selfharm antisocial behaviour cannabis or illicit noncannabis drug use or risky sexual behaviour among males and females were associated with a 50 increase in likelihood of ipva victimisation or perpetration males reporting depression sexual abuse not by an intimate partner witnessing domestic violence or parental separation were also more likely to experience ipva extreme parental monitoring high academic achievement during adolescence and neet not being in education employment or training status in young adulthood were associated with reduced risks of ipva conclusions a range of demographic mental health and behavioural factors were associated with increased prevalence of ipva victimisation or perpetration further study of likely complex1 2 version 3 revision

getting the terms right what is impact entertainment the englishlanguage literature uses the term social impact entertainment to describe the use of cinema as a means of influencing public opinion and public awareness typically such content covers a wide range of societal issues such as the environment cultural differences racial and gender issues and others there is no similar term in russian but impact entertainment or social impact cinema can be used instead the term also received a definition at the vedomosti media business conference in 2012 albeit a narroweddown one which only referred to drawing attention specifically it was an entertainment content production and distribution system that draws the audience attention to issues of social importance 1 that is the kind of content that does not only entertain the viewers but also enables a discussion of important topics that would likely be left in obscurity if not shown on screen it is important to note that social impact is a running theme in the entertainment industry playing an important role figure 1 2 shows the relationship between impact entertainment and mainstream content production the chart shows that social impact is an integral part of the entertainment industry without being a separate development sector or part of a development sector igor mishin ceo mts media has the same view of the phenomenon which he shared at the aforementioned conference social impact content doesnt have to be something special viewers should love it and accept it normally just like any other type of content no need to take this topic into a reservation 1 how do we go from declaring the importance of impact to measuring it and even guaranteeing that our goal is achieved the global practice for assessing the impact of a motion picture is to use interdisciplinary tools aimed at measuring the social impact of content in particular the interest in assessing the social impact of a motion picture is related to the fact that such content can become a tool for addressing vital social and environmental issues by appealing to the public opinion in this regard social impact assessment tools are integrated into all stages in the development and production of film projects as well as after their completion just like with any project involving social change to be achieved о терминах что такое импактинтертейнмент для обозначения социального воздействия кино в англоязычной литературе используется термин «social impact entertainment» который трактуется как использование кинематографа в качестве средства воздействия на общественное мнение и сознание как правило такой контент охватывает широкий круг общественных проблем таких как экология культурные различия расовые и гендерные вопросы и другие в русском языке аналогичного термина не существует но можно использовать «импактинтертейнмент» или «социальный импакт кино» в 2012 году на конференции «ведомостей» посвященной медиабизнесу также было дано определение этому термину но в сокращенном значении касающемся только «привлечения внимания» это «система производства и дистрибуции развлекательного контента привлекающая внимание аудитории к общественно значимым проблемам» 1 то есть такой контент позволяет не только развлечь зрителей но и обсудить важные темы которые не попали бы во внимание если бы их не увидели на экране важно отметить что в индустрии развлечений социальный импакт является устойчивой нормой и играет важную роль на схеме представленной на рисунке 1 2 можно увидеть соотношение между импактинтертейнментом и мейнстримным производ ством контента эта диаграмма показывает что социальный импакт является неотъемлемой частью развлекательной индустрии не являясь при этом отдельным сектором или частью сектора развития такое же представление о явлении высказано на вышеупомянутой конференции игорем мишиным гендиректором «мтс медиа» «social impact контент не должен быть чемто особенным зрители должны его любить и воспринимать обычно как любой другой вид контента не надо эту тему уводить в резервацию» 1 как перейти от декларации о важности импакта к его измерению и даже гарантии достижения поставленной цели для оценки импакта кино в мировой практике используются междисциплинарные инструменты направленные на измерение социального воздействия контента в частности интерес к оценке социального импакта кино связан с тем что такой контент может стать инструментом решения важных социальных и экологических проблем посредством обращения к общественному мнению в связи с этим инструменты оценки социального воздействия кино внедряются на всех этапах разработки и производства кинопроектов а также по их окончании по аналогии с любым проектом предполагающим достижение социальных изменений social sciences film as a multidimensional subject researchers assessing the social impact of motion pictures use various impact assessment tools the methods focus on different aspects of the social impact of the motion picture and study different subjects the content of the film or the perception of the audience one method is surveys which involve collecting data from large groups of people about their attitudes opinions and behaviors related to film products for example a survey could be about how the film influenced viewers opinions on a particular topic longitudinal studies track the same people or group over an extended period to see how their experience with film changes and develops over time content analysis examines the content of films identifies their topics and messages and assesses their potential of influencing the audiences ethnographic research helps us understand how a community perceives film and how cultural context affects that perception социальные науки кино как многомерный предмет исследования исследования социального воздействия кино используют разные методы для оценки его влияния методы фокусируются на разных аспектах социального воздействия кино имея разные предметы исследования содержание фильма или восприятия зрителей так опросы подразумевают сбор данных от больших групп людей об их отношении мнениях и поведении связанных с продуктами кинематографа например опрос может быть о том как фильм повлиял на мнение зрителей по определенной теме лонгитюдные исследования отслеживают одних и тех же людей или группу в течение определенного периода времени чтобы увидеть как меняется и развивается их опыт общения с кино контентанализ изучает содержание фильмов выявляет их темы и сообщения а также оценивает потенциал влияния на аудиторию этнографические исследования помогают понять как сообщество воспринимает кино и как культурный контекст влияет на это восприятие развлечение entertainmentdriven позитивные изменения the social effects of cinema at the social attitudes level are not linear they involve many other related variables and vary depending on the assessment method and indicators selected however some tools based on the methods used in social sciences have long been used in filmmaking university of birmingham professor finola kerrigan in her book on film marketing lists the following tools in this category concept testing positioning studies test screenings focus group testing advertising testing and exit polls • concept testing this step assesses the potential for commercialization and success in the market so as to determine the film budget this can be viewed as part of the production process because it can influence decisions such as script development and actor selection • positioning studies this type of research analyzes elements that can act as marketing assets of a film marketers test the potential profitability of a film based on audience response to the genre cast and specific characters • test screenings there are two types of test screenings in the film industry b2b for business partners and b2c for ordinary viewers in the first case film screenings are held for film distributors as part of private screenings or film festivals such tests are used to learn the partners opinions as well as to attract them to the project in the case of test screenings for viewers the target audience members involved are invited to watch the film before the final version it is here that changes can be made to the film such as replacing the ending in rambo or changing the drawing of characters in the pikachu film the respondents are selected by social and demographic qualities and are interviewed before and after watching the film during the screening researchers observe their reactions and some of the invited viewers participate in a focus group after the screening • testing of marketing materials posters trailers postcards and advertisements can be tested in focus groups to make sure they match the cultural codes of the target audience and are understood by them as ruth vasey author of a film research guide writes hollywoods peculiarity lies in the dichotomous nature of its show business which combines the financial imperatives of business with the ephemeral appeal of show there is an entire genre of articles in the hollywood reporter discussing how the results of социальные эффекты кино на уровне социальных установок не являются линейными включают в себя много других сопутствующих переменных также они варьируются от способа оценки и избранных индикаторов однако существуют инструменты основанные на методах социальных наук которые давно используются в кинопроизводстве профессор бирмингемского университета финола керриган в своей книге по маркетингу фильма особенность голливуда состоит в дихотомической природе его «шоубизнеса» которая сочетает финансовые императивы «бизнеса» и эфемерную привлекательность «шоу» существует целый жанр статей в журнале the hollywood reporter посвященных обсуждению того как результаты тестовых показов test screenings influenced marketing decisions for a particular film from the same magazine you can learn 3 that test screenings were kept as part of the mandatory film preparation program even during the covid19 pandemic because their results could lead to both additional filming and higher chance for success overall we can conclude that cinema is an attractive and promising area for research at the same time representatives of different scientific disciplines use their own conceptual apparatus and formulate their own research questions related to this area in particular for a sociologist cinema can be of interest in terms of representing social situations and phenomena as described in vadim radayevs sociological essays there is even a special academic discipline cinema studies which treats film as a separate semiotic space the junction between the viewers perception and the film plot can also be studied from the perspective of psychology from a linguistic point of view there have been interesting studies on fictional languages from films such as the na vi language from the avatar universe marketing assessment methodology and cultural strategy it is worth noting that neither social science nor psychology offers any readymade recipes on how to incorporate their methods into the filmmaking process nor do they aim to do so the methodologies that include conducting research and considering its results as part of project activities are primarily developed by the actual stakeholders the filmmaking community itself in the united states an association for impact entertainment has been established the social impact entertainment society this association has a specially developed guide to impact assessment the four impact dynamics 4 notably these four elements mirror the social impact ladder and appeal to the logic of the theory of change the theory of change is the basic element of the social project evaluation model connecting the links in the chain of a projects social outcomes the social impact ladder describes a chain of social outcomes in terms of successive changes in the perceptions attitudes and behaviors of target audiences as well as changes in communities and society at large повлияли на маркетинговые решения в отношении того или иного фильма из этого же журнала можно узнать 3 что даже во время пандемии тестовые показы не были исключены из обязательной программы подготовки фильма поскольку их результаты могут привести как к проведению дополнительных съемок так и к повышению ожиданий на успех в целом можно заключить что кино является привлекательной и перспективной областью для исследований при этом представители разных научных дисциплин используют свой собственный концептуальный аппарат и формулируют свои исследовательские вопросы связанные с этой сферой в частности для социолога кино может представлять интерес с точки зрения репрезентации социальных ситуаций и явлений как это описывается в социологических очерках вадима радаева существует отдельная академическая дисциплина cinema studies которая рассматривает кино как самостоятельное семиотическое пространство можно изучать стык восприятия зрителя с сюжетом фильма с позиции психологии с точки зрения лингвистики есть занимательные случаи исследования выдуманных языков из фильмов например языка на ви из киновселенной «аватар» маркетинг методология оценки и культурная стратегия стоит сказать что ни социальные науки ни психология не предлагают никаких готовых рецептов о том как встраивать свои методы в процесс кинопроизводства методологии которые бы включали в себя проведение исследования и учет его результатов как часть проектной деятельности разрабатываются в первую очередь самими интересантамисообществом кинематографистов в сша существует ассоциация для импактинтертейнмента одноименная social impact entertainment society у этой ассоциации есть специально разработанное руководство по оценке импакта «четыре динамики воздействия» 4 to plan for impact you must have a strategy lined up for the film its mission its image of social change its target audiences and the appropriate messaging • artistic vision the inner vision of the film and of what it will be like it is determined by the director and creative crew selected by the director • the vision of the impact is the external vision of what the film will do it is determined by the entire project team including those in charge of public relations history narrative and culture come together through theory of change into a cultural strategy in which practitioners collaborate with the entertainment industry executives writers and producers to shape positive images of socially excluded communities and raise awareness of social issues produce and distribute their content the basic principle behind the cultural strategy is that entertaining stories can influence public opinion and perception by fostering cultural dialog and public participation which is used in social policies aimed at stimulating social justice cultural strategy refers to social results in media projects and is built on the principles of educationentertainment an area at the junction of impact entertainment and educational projects it is an established industry with clear methodologies and principles a textbook on this direction of filmmaking cites a motion picture series made in south africa as an example an 18month study was conducted to produce the series which included indepth interviews with social activists and government officials case studies of women surviving violence and audience research to implement the studys findings it was decided to focus the campaign on overcoming the structural barriers that prevented women from seeking help the script was based on the materials from the interviews and group discussions for example character positioning was lined up based on focus group surveys and audience feedback during test readings of the script and social issues were sewn into the fabric of the drama терминах последовательных изменений на уровне представлений отношения и поведения целевых аудиторий а также изменений в жизни сообществ и общества в целом согласно упомянутому руководству 4 уровня импакта в культурном производстве включают в себя история нарратив и культура объединяются посредством теории изменений в культурную стратегию при которой практики сотрудничают с руководителями писателями и продюсерами индустрии развлечений чтобы формировать положительные образы социально исключенных сообществ и повышать осведомленность в части социальных проблем производить и распространять свой контент основной принцип заложенный в культурной стратегии заключается в том что развлекательные истории могут оказывать влияние на общественное мнение и восприятие способствуя культурному диалогу и общественному участию что используется в социальных политиках направленных на стимулирование социальной справедливости культурная стратегия относится к социальным результатам в медиапроектах и строится на принципах educationentertainmentобласти на пересечении импактинтертейнмента и образовательных проектов в рамках нее существуют четкие методики и принципы поскольку она представляет собой сформировавшуюся индустрию в хрестоматийной книге об этом направлении кинопроизводства приводится пример сериала из юар для производства этого сериала было проведено 18месячное исследование которое включало в себя глубинные интервью с социальными активистами и представителями госучреждений исследование случаев женщин пострадавших от насилия а также исследование аудитории в качестве имплементации находок исследования было решение сфокусировать кампанию на том чтобы преодолеть структурные барьеры которые мешали женщинам обращаться за помощью материалы интервью и групповых обсуждений as an example of the use of four impact dynamics we can refer to the crew experience of the us motion picture the hunting ground this example stands out due to its comprehensive use of the assessment tools for the study of the social results achieved as well as its integration of the media project and research the team used theory of change to mobilize student interest and engage university leadership in new practices the crew held 70 screenings at 33 universities they also worked with student leaders at conferences and national meetings where the film was used to influence campus life the project team used the four impact dynamics methodology to assess the social impact of the film they worked with human rights activists and university associations to conduct a survey about sexual violence on campuses among the students on all campuses across the country the following indicators were developed student reactions to the screenings and followup activities university staff and students requests for screenings adoption of violence prevention training programs by universities and implementation of new policies recommended based on the results of the survey the results of the teams work showed increased interest among students and university administrators in the issues raised in the film and led to the introduction of new policies to combat sexual violence among the students the applicability of the four impact dynamics methodology to assess social impact of a motion picture is recognized by the media impact assessment community and used to assess the effects of impact entertainment its advantage is consistency with the steps of the impact ladder and the project logic of the theory of change therefore it can be used as the basis for designing and building an impact assessment system for motion pictures however it is also worth noting the limitations of four impact dynamics estimating impact as the final stage использовались для написания сценария например позиционирование персонажей выстраивалось на основании опросов целевых групп и обратной связи аудитории в ходе тестовых читок сценария а социальные проблемы «зашивались» в особенности драмы в качестве примера с применением four impact dynamics можно привести опыт команды работавшей над американским фильмом «зона охоты» он выделяется по степени полноценности оценочных средств для исследования достигнутых социальных результатов а также по степени интеграции медиапроекта и исследования команда использовала теорию изменений чтобы мобилизовать интерес студентов и вовлечь руковод ство университетов в новые практики команда организовала 70 показов в 33 университетах они также работали с лидерами студенческих организаций на конференциях и национальных встречах где фильм использовался для влияния на жизнь кампусов команда использовала методологию four impact dynamics для оценки социального импакта фильма они работали с правозащитными и университетскими ассоциациями для проведения опроса о сексуальном насилии на кампусах проведенного студентами во всех студенческих городках страны были разработаны следующие индикаторы реакции студентов на показы и последующие мероприятия запросы университетов на показы для сотрудников и студентов принятие обучающих программ по предотвращению насилия университетами и внедрение новых политик рекомендованных на основании результата опроса результаты работы команды показали повышение интереса студентов и руководства университетов к проблемам затронутым в фильме а также привели к введению новых политик по борьбе с сексуальным насилием в студенческой среде применимость методологии four impact dynamics для оценки социального импакта кино является признанной в сообществе оценки импакта в медиасфере и используется для оценки импактфильмов ее преимуществом является согласованность со ступенями лестницы воздействия и проектной логикой теории изменений таким образом она может быть использована как чтобы спланировать воздействие необходимо иметь выстроенную стратегию в отношении фильма его миссии образа социальных изменений целевых аудиторий и соответствующих месседжей to plan for impact you must have a strategy lined up for the film its mission its image of social change its target audiences and the appropriate messaging results needs an overly complicated model the scope of subjects and film formats to which this methodology is applicable is also limited russias experience in evaluating the social impact of cinema when discussing the social impact of cinema it is important to clarify that not all studies cover this social aspect of film production social impact is a subject of research that falls into the evaluation of social programs and policies while it is possible to consider the plot language and audience perceptions of a film outside the context of social impact one russian study that addresses social impact but does not conduct or implement evaluation of a film instead focusing on creating the conditions for mapping is a study by the center for social projects platforma supported by the national media group the aim of the study was to develop a social impact index and a map of films having social impact taking into account both domestic and foreign experience the study generated a list of 28 films released in 20212022 and identified by experts as having social impact as well as a coverage rating and an impact map of the films based on 11 parameters reflecting the films impact on the audience in order to create a map of social impact films we used the results of a mass quantitative survey of russian cities with more than 100000 population in which respondents chose up to five films they had seen and rated each film by 11 parameters reflecting its impact on the audience the study concluded that social impact films should consider the balance between popularity and social message and not alienate the viewer by evoking negative emotions one of the challenges of social impact films is to engage and retain the viewer cinema should be entertaining and emotional as well as provide answers to the viewers questions and support them in a challenging situation it is hard to argue that these findings were unknown prior to the study notably the authors use an integrated approach that includes both a common marketing framework for social impact assessment and a set of some social research methods speaking about the differences between this study and the testing practices in film production mentioned above we can highlight the following points • the platforma study is done postfactum after the films have been released and is not a part проектная основа для построения системы оценки импакта кино тем не менее стоит отметить и ограничения four impact dynamics для оценки импакта как конечного этапа воздействия требуется серьезное усложнение модели также ограниченной является та сфера сюжетов и форматов фильмов в которой возможно применение этой методологии и в целом внедрение принципов импактинтертейнмента российский опыт оценки социального импакта кино при обсуждении социального импакта кино важно уточнить что не все исследования охватывают данный социальный аспект кинопродукции социальный импакт представляет собой предмет исследования из области оценки социальных программ и политик в то время как можно рассматривать сюжет киноязык и восприятие зрителей вне контекста социального воздействия среди российских исследований которые обращаются к социальному импакту но при этом не проводят и не внедряют оценку фильмов но создают условия для картирования стоит выделить исследование цсп «платформа» при поддержке национальной медиа группы целью исследования стала разработка индекса социального влияния и карты фильмов с социальным эффектом учитывая как отечественный так и зарубежный опыт в рамках исследования были сформированы список из 28 киноработ вышедших в 20212022 годах и определенные экспертами как имеющие социальный эффект а также рейтинг состоящий из охвата и индекса влияния фильма рассчитанного на основе 11 параметров отражающих влияние фильма на зрителя для того чтобы составить карту фильмов с социальным эффектом были использованы данные массового количественного опроса городов рф с населением более 100 тыс человек в ходе которого респонденты выбирали максимум 5 фильмов из числа тех которые они видели и оценивали каждый фильм по 11 параметрам отражающим влияние фильма на зрителя в результате исследования были сделаны выводы что социальное кино должно учитывать баланс между популярностью и социальным посланием а также не отталкивать зрителя вызывая негативные эмоции одним из вызовов социального кино является вовлечение и удержание зрителя кино должно быть развлекательным и эмоциональным а также давать ответы на вопросы зрителя и поддерживать его в трудной ситуации трудно утверждать что эти выводы были неизвестны до проведения исследования примечательно что авторы используют интегрированный подход который включает как общий фреймворк из маркетинга для оценки социального воздействия так и набор некоторых методов социального исследования говоря про отличия этого исследования от упоминавшихся ранее практик тестирований в рамках кинопроизводства можно выделить следующие моменты of the filmmaking process that could have an effect on the final appearance of the film • the study is conducted without focusing on specific films that is it does not focus on the media effects narrative features and special effects of a specific film whose crew is involved in the study design • the study methods focus on the interpretation by an undetermined sample of viewers so that there remains room for improvement of the approach by refining the sample of surveys • the study does not include test screenings an important element of applied research tools • the only data source used is a survey without the qualitative perspective of researching the plot of the film however the most important point worth noting in the platforma study is that social impact is the final element in a complex chain of social effects which cannot be proven by referring to postfactum social surveys of an undetermined number of individuals without identifying the target groups the social issues raised by the films the effects of specific films on communities the study still fails to map films by their social effect as you read the report the question arises what is the social significance of the selected films we can conclude that there is room for expanding the available set of tools for more effective research into the social significance of russian cinema and incorporating them into the film production process possible applications of the assessment of the social impact of cinema impact entertainment is the use of cinema to influence public opinion and awareness in addition to entertaining viewers social impact перспективы оценки социального импакта кино импактинтертейнмент это использование кинематографа для воздействия на общественное мнение и сознание контент с социальным воздействием не только развлекает зрителей но импакт представляет собой предмет исследования из области оценки программ и политик в то время как можно рассматривать сюжет киноязык и восприятие зрителей вне этого контекста impact is a subject of research that falls into the evaluation of programs and policies while it is possible to consider the plot language and audience perceptions of a film outside this context content also promotes a discussion of important topics which can lead to increased awareness on various global issues and a change in social attitudes through the broadcasting of behavioral patterns impact entertainment is an integral part of the entertainment industry existing within the framework of mainstream content production the social impact of cinema is explored through numerous methods borrowed from the social sciences both qualitative and quantitative methods can be used to cover different aspects of the films social impact for example surveys and longitudinal studies deal with viewers attitudes and behaviors content analysis deals with film content and ethnographic studies address the cultural context of film perception the perspectives of content analysis and perception can be combined using for example experimental psychosemantic methods different social research methods are used in film industry to focus on different aspects of the films social impact applied research tools such as concept testing positioning studies focus group testing test screenings advertising testing and exit polls are used during the film production they help assess a films potential in the marketplace and make decisions about script development and actor selection marketing tools such as project planning can be used to integrate social impact studies into the filmmaking process the russian experience of assessing social impact of a film is based on applying a combined framework of marketing and social science methods the distinguishing feature of this study is that it is done after the films have been released and is not a part of the production process that could have had an effect on the final appearance of the film no test screenings were conducted as part of the study and only an unspecified sample survey is used the use of applied tools to determine the social impact of russian films involves the integration of a research component into the film production process moreover developing a cultural strategy that involves social impact assessment and design can contribute to greater social impact this is how the image of evidencebased approach in the film industry emerges the experience we have reviewed allows us to conclude that the field of social impact assessment in the film industry has a large number of growth points one possibility is to develop an assessment model based on the projects theory of change it involves describing the assessment tasks indicators and methods at each stage of the development creation and final evaluation of a film product accordingly there are three types of evaluation predictive evaluation during the preparation phase monitoring after the launch of the film project and impact assessment in the period of the anticipated achievement of social effects as part of the evidencebased filmmaking strategy developed research tools are adapted to different types of materials script intermediate materials finished content informational materials etc и позволяет обсудить важные темы которые могут привести к повышению осведомленности людей о различных проблемах в мире и к изменению общественных установок через трансляцию поведенческих моделей импактинтертейнмент является неотъемлемой частью развлекательной индустрии существуя в рамках мейнстримного производства контента социальный импакт кино исследуется с помощью многочисленных методов из социальных наук они могут быть качественными или количественными а также работать с разными аспектами социального воздействия кино например опросы и лонгитюдные исследования работают с мнениями и поведением зрителей контентанализ с содержанием фильма а этнографические исследования с культурным контекстом вос приятия фильмов для объединения перспектив анализа контента и его восприятия могут быть использованы например экспериментальные методы психосемантики существуют различные методы социальных исследований в кино которые фокусируются на разных аспектах социального воздействия кино во время производства фильма используются прикладные исследовательские инструменты такие как проверка концепции исследование позиционирования тестирование фокусгруппами тестовые показы тестирование рекламы и опросы на выходе они помогают оценить потенциал фильма на рынке и принимать решения о разработке сценария и выборе актеров инструменты проектного планирования из маркетинга могут быть использованы для встраивания исследования социального импакта в процесс кинопроизводства рассмотренный российский опыт оценки социального воздействия кино основан на применении фреймворка из маркетинга и методов из социальных наук отличительная черта этого исследования заключается в том что оно проводится после съемок фильмов и не является частью кинопроизводства которая могла бы повлиять на облик фильма в рамках исследования не проводилось тестовых просмотров а используется только опрос не определенной выборки использование прикладных инструментов для определения социального влияния отечественного кино предполагает внедрение исследовательской составляющей в кинопроизводство более того разработка культурной стратегии с оценкой и проектированием социального воздействия может способствовать достижению большего социального эффекта так возникает образ доказательного подхода в киноиндустрии рассмотренный опыт позволяет заключить что область оценки социального импакта в кинематографе обладает большим числом точек роста одной из возможностей является разработка модели оценки на основании теории изменений проекта она предполагает описание задач индикаторов и методов оценки на каждом из этапов разработки создания и финальной оценки продукта кинематографа соответственно выделяются три вида оценки прогностическая оценка на этапе подготовки мониторинг it should be noted that russia currently lags behind in the field of evidence and has only a superficial level of discussion regarding the assessment of film products the term impact media is far more popular than what is being done at the real scale to rigorously and reasonably assess film products selfassessment expert review by the project team and other approaches that are subjective and prone to wishful thinking are more common than conducting objective research and studying audience opinions and feedback in this context the phenomenon of impact washing is created as players begin to add the word impact to the names of their companies or positions for example we now have impact directors instead of ordinary directors which however does not lead to any significant changes in their work we assume that once the market is saturated with experts capable of conducting research of sufficient complexity it will become indecent to talk about creative products being immeasurable or about the possibility of using the concept of impact in relation to simple social effects or about drawing conclusions based on a sample of a few people после запуска кинопроекта и оценка воздействия в период предполагаемого достижения социальных эффектов в рамках выстроенной стратегии доказательного кинопроизводства используются исследовательские инструментарии адаптированные под различные типы материалов сценарий промежуточные материалы готовый контент информационные материалы и т п необходимо отметить наличие в россии лага в области доказательной базы и поверхностного уровня дискуссии относительно оценки продуктов кинематографа популярность термина «импактмедиа» значительно превышает в реальном масштабе то что делается для строгой и обоснованной оценки продуктов кинематографа самооценка экспертиза командой проекта и другие подходы связанные с низкой объективностью и высокой степенью риска выдать желаемое за существующее более распространены чем проведение объективных исследований и изучение мнений и отзывов аудитории в этом контексте появляется феномен импактвошинга игроки начали добавлять слово «импакт» к названиям своих компаний или должностей например появились не просто режиссеры а импактрежиссеры что однако не приводит к существенным изменениям в их деятельности представляется что с насыщением рынка экспертами способными проводить исследования достаточной сложности станет неприличным говорить о неизмеримости творческих продуктов о допустимости использования понятия «импакт» в отношении простых социальных эффектов а также делать выводы на основании выборки из нескольких человек список источников

кино один из любимых видов искусства у людей разного возраста так же как и музыка театр архитектура литература или живопись кино безусловно оказывает воздействие на человека при этом оно может не только привлекать внимание к социальным проблемам но и обладает потенциалом менять установки и модели поведения людей а значит и мир в целом данная статья представляет собой обзор подходов к проведению исследований социального воздействия кино и поднимает ряд важных вопросов связанных с текущим состоянием отрасли измерений импакта в кино cinema is one of the most popular art forms among people of all ages just like music theater architecture literature or painting cinema certainly has an impact on people at the same time it has the capability to not just draw attention to social problems but also to change peoples attitudes and behaviors thus changing the world as a whole this article provides an overview of various approaches to researching social impact of motion pictures and raises a number of important issues related to the current state of the impact assessment industry in motion picturesоценка социального импакта кино и практики доказательности в кинопроизводстве

in todays hectic world technological advancements are widely embraced without considering their negative impacts on human agency these downsides encompass a multitude of issues for instance technological devices can be used by those in authority as a means of monitoring and controlling people peoples actions which can lead to their getting robbed of their agency on the other hand the rise of superadvanced technology can also make workers redundant thus causing unemployment on a large scale in fact technologies have the capability of replacing human labor the emergence of influential figures such as elon musk who heavily invest in projects such as neuralink that are directly related to artificial intelligence signals a rapid transition from a humanist to a posthumanist era zizek avers that neuralink is a company which is focused on creating devices that can be implanted in the human brain with the eventual purpose of helping human beings to merge with software the shift in technology and its relation to human beings implies reevaluating the meaning of humanity and agency as we become more dependent on technology from a psychoanalytic and philosophical perspective slavoj zizek probes into the profound impact of technology and ideology on human agency he believes that science and technology go hand in hand to create novel forms of life altering human nature throughout his books he thoroughly examines how the impact of such developments shapes our selfperception interpersonal connections and our societal role through an analysis of the interplay between ideology power structures and technology zizek aims to decipher how authority establishes its dominance in society regarding the concept of technology he takes note of the fact that the goal is no longer just to dominate nature but to generate something new greater stronger than ordinary nature including ourselves by which he means the technology can radically change the true essence of human being kurt vonnegut an esteemed american author personally experienced the growing influence of technology throughout his lifetime as farrell asserts vonnegut relied on a typewriter instead of a computer to type his stories and essays his debut novel player piano was inspired by his experiences at general electric where he grappled with groundbreaking ideas about advanced technology according to harold bloom vonneguts first novel player piano depicts a nightmarish superstate of the future in which the worship of technology has all but extinguished the human spirit the fictional narrative of vonnegut attempted to explore the implications of an extremely automated society in which machines increasingly replaced human labor giving rise to questions about the role of human beings and the erosion of human agency volume 5 issue 3 2023 both zizek and vonnegut offer valuable insights into the complex relationship between technology ideology and human agency they introduce various ideas illuminating the multifaceted challenges of digitalization urging us to have a critical viewpoint on the effects of these advancements literature review the realm of technology studies presents a diverse range of theoretical frameworks due to the fact that we are inhabiting an age where humans are increasingly intertwined with advanced technology considerable attention is being paid to the issue of how it affects us a multitude of great philosophers have written influential books on technology and how it affects humans including bernard stiegler donna haraway neil badmington and katherine hale to name a few for instance stiegler a french philosopher has a complex and nuanced view of technology bernard stiegler in technics and times does not tell us that technology is banishing us to hell instead in examining the effect of technology on human beings he asserts that there are technologies however that exist because of us he believes technology is not inherently good or bad rather it is a tool that can be used both positively and negatively moreover donna haraway is widely recognized as one of the radical thinkers in technology in her famous work cyborg manifesto she argues that technology is more than a tool but that humans and technology are intertwined she also associates technology with gender roles asserting that it can challenge traditional gender roles allowing for more diverse forms of embodiment and expression as a metaphor for hybridity and intersectionality she uses the idea of the cyborg as a means of breaking down boundaries between nature and culture human and machine and male and female she also argues that gender is socially and culturally constructed rather than driven by biological determinism slavoj zizeks theorization of the potential dangers of digital control is one of many conceptual frameworks in the realm of digitalization which forms the underlying theoretical framework of the article harrison bergeron portrays a socalled utopian society where everyone must be equal to each other which seems incredible at first but you will realize the purpose behind this equality utilizing technological advances and promoting the idea of egalitarianism government authorities have the power to control people both physically and mentally the dystopic society of harrison bergeron has been under thorough analysis in light of different criteria such as equality and freedom apocalyptic narrative and dehumanization methodology even though there have been studies on harrison bergerons ideological society and technocratic society of player piano few have examined how ideology is tied to technology and how ideological subjects are stripped of agency and freedom therefore it is necessary to study how the illusion of freedom is presented to ideological subjects and how their agency is taken away through various technological mechanisms there appears to be a lack of critical studies analyzing in light of theories concerning technology and ideology to fill this gap in the literature the current study will apply zizeks theories regarding the dynamic relationship between technology ideology and individual agency the primary f approach applied in the current literary study is textual analysis therefore vonneguts novels will be brought under meticulous analytical scrutiny and thus analyzed in light of zizeks theories this paper examines the ideology and its association with technology disseminated throughout society specifically it argues that individuals like george and hazel perceive their lack of freedom as ultimate freedom in a society where everything is governed by ideology moreover the paper aims to broaden the readers horizons regarding the potential risks and challenges associated with our growing reliance on advanced technology thus the purpose of this article is threefold in the first step in mapping zizeks theory of freedom it aims to explain how slavery is sold to ideological subjects secondly by utilizing zizeks theory of digitalization it is argued that technology can pave the way for the dehumanization of the ideological subjects as long as those in authority leverage technology to impose their ideology the papers final section focuses on how the agency of ideological subjects is undermined in a society where technology is so advanced that the government uses it to rob the ideological subjects of their agency 31unfreedom in the guise of freedom kurt vonnegut in harrison bergeron portrays a society where strict government laws enforced by diana moon glampers have ensured equality for all citizens these changes in equality were the product of the 211th 212th and 213th constitutional amendments and of the unceasing vigilance of the united states handicapper general the novel player piano also examines the struggles the characters have with the system for instance the protagonist paul proteus initially accepts the benefits of his social position within the technological society however as the novel progresses his disillusionment grows and he seeks a sense of purpose and freedom in harrison bergeron vonnegut illustrates that the harsh rules imposed by the government agents ensure equality for all citizens which results in constant surveillance of the subjects at the hands of moon glampers moreover mentioning the unceasing vigilance indicates the extent of control and monitoring in the dystopian society of this story therefore people who are more beautiful intelligent and strong or have any ability that classifies them as above average are compelled to wear handicaps to be considered normal while this normality may bring about freedom and equality it results in the loss of the characters agency in addition the pervasive monitoring by the handicapper general prevents analytical thinking and critical questioning of the government rules are at the forefront of player piano as they play a significant role in determining not only how the characters live but also how society functions the government and large corporations are the primary generators and enforcers of the amendments as they serve to maintain order as well as controlling the population they are designed to limit peoples freedom and impose limits on their lives emphasizing efficiency and productivity over technology and human agency in kurt vonneguts harrison bergeron and player piano individuality and fulfillment throughout the novel the characters especially dr paul proteus grapple with the devastating effects of the rules on their lives to the extent that at the end of the novel he decides to overthrow the oppressive system as illustrated in the story george who is both physically and mentally handicapped does not have the propensity to change his oppressive living conditions this becomes evident when hazel implores him to take out the handicaps yet george shows no inclination to violate the enforced rules two years in prison and two thousand dollars fine for every ball i took out furthermore george by referring to the past tries to dissuade hazel from any transgression that goes against the rules in society by attributing competitions to the dark ages it can be implied that authorities have blocked any sort of progress as george avers getting away with it would encourage others to do the same and pretty soon wed all be back in the dark ages with everyone competing against each other you wouldnt like that would you precluding people from competing with each other not only does not make everybody equal but also prevents them from improving an objective that aligns entirely with the desires of the power figures moreover despite his handicaps george is depicted as a compliant member of society who unquestioningly accepts his predetermined fate and adheres to the governments rules he is also afraid of the potential consequences of rebellion and is seemingly content with forced egalitarianism even at the expense of sacrificing his potential in his book the zizek dictionary rex butler argues that freedom according to zizek is a false consciousness in which we lack the language to express our unfreedom moreover zizek posits freedom is most threatened by our experience of nonfreedom as freedom not by an openly authoritarian power examining george and hazels dialogues reveals how being mentally and physically fettered is regarded as freedom for them being less intelligent hazel goes so far as to imagine herself in the place of the government agent and does not care about their child who has been taken to prison additionally in player piano paul gradually becomes mindful of his illusory freedom which results in his being exposed to the dangerous aspects of a society in which nonfreedom is sold as freedom to ideological subjects initially paul is a highly prosperous engineer who benefits from the system thus satisfied with his social position as time passes by he becomes the most emblematic example of an individual who experiences his lack of freedom as freedom regarding himself as a successful person on the other hand in harrison bergeron despite georges physical handicap he does not perceive it as a state of unfreedom conversely zizeks idea resonates strongly with the volume 5 issue 3 2023 situation presented in the story he posits that ideological subjects can be easily controlled and that they willingly adhere to the enforced rules as long as they experience freedom within an ideological society in other words individuals in an ideological society may believe they are free to make choices therefore they willingly abide by imposed rules allowing them to take control of their actions and thoughts in the story george directly influenced by the generals manipulative rules has internalized both the rules and beliefs of those in power which distracts him from thinking critically about the government this is what paul experienced in the technocratic society of player piano in fact the novel highlights the potential risks associated with a society that masks the true nature of freedom thus perpetuating a collective illusory notion of freedom that way the subject is more inclined to consider himself a free entity and believe he is making the right choice by not doing anything against the rules considering this georges perception of freedom in harrison bergeron is completely deceptive not only is slavery sold to him as freedom but also it masks the underlying reality of his exploitation as a result george is unable to see the true nature of his situation because he has an illusion of choice and the feeling of freedom another facet of zizeks theory of freedom is the concept of interpassivity zizek defines it as to participate actively not only in the spectacle itself but more and more in establishing the very rules of the spectacle it means that one does not engage directly in the decisionmaking process instead they leave this responsibility to their representative interpassivity is evident in this story through the implementation of strict rules in harrison conbergeron the ideological subjects fail to engage with their true potential actively instead their agency is suppressed by external handicaps leading them to passively abide by imposed rules by accepting and following the decisions of the handicapper general the characters act according to her policies without critically examining the regulations which can lead to the perpetuation of existing power structures and ideologies thus individuals may be conducive to reproducing injustice and inequality and injustice inadvertently by relinquishing agency to external agents moreover these handicaps play a major role preventing individuals from fully recognizing their abilities and passions thereby hindering them from discovering their true selves the same situation exists in the novel player piano they have left everything to technological devices it is also visible through the ubiquity of machines and automation as machines perform all significant tasks people become mere observers passively taking in the world technology and human agency in kurt vonneguts harrison bergeron and player piano around them in fact interpassivity is reflected in this passive acceptance of technological dominance in fact interpassivity emerges once individuals acquiesce passively to the imposed limitations within an ideological society in the short story under analysis no one dares to question the oppressive regime except for harrison bergeron at the end of the story instead they would rather internalize the rules to achieve the promised equality without critically examining its downside for instance george blindly abides by his situation and he always tries to be a model citizen in the eyes of the big other as a result they turn into passive subjects by surrendering themselves to the superimposed restrictions on the contrary for zizek domination of those in authority does not seem to encroach upon ideological subjects freedom in society he then goes on to aver that freedom must appear as individuals experiences of freedom while struggling for promised equality george remains indifferent to handicaps since his beliefs have been shaped based on the big others beliefs however there are some parts of the story that reveal georges analytical contemplation of the governments rules for instance in the scene where the ballerinas are dancing george believes that they should not wear handicaps and at the same time that he is thinking about this a big noise interrupts his thoughts his critical thoughts are interrupted and he cannot think analytically for more than a few seconds vonneguts depiction of thought control is in line with zizeks statement which posits that the legalideological matrix of freedomequality is not a mere mask concealing exploitationdomination but the very form in which the latter is exercised on this occasion he suggests that freedom and equality themselves are the very means through which those in authority can exercise domination and exploitation by submitting to the rules unconditionally ideological subjects such as george and hazel allow the government to dominate them resulting in their son not even being recognized in fact through the fantasy of equality and freedom they lure george and hazel into conforming to the strict rules such as wearing heavy handicaps we are then given a way forward by zizek for living in an ideological system that rules everything in society in any possible way a compromise is necessary here a combination of fighting illusory utopian expectations and giving people enough security to accept the system firstly zizek argues that one must put unrealistic and overly idealistic expectations aside people with illusory utopian expectations think that a flawless society is possible where all issues are solved and everyones needs are met in the real world such expectations are not achievable and can cause ideological subjects to be disappointed instead he believes one should acknowledge the limitations and imperfections of their system this way people are able to approach the system more realistically and pragmatically the first thing that george in harrison bergeron and other ideological subjects such as paul has to realize is that there is not going to be any utopian society in which everything is according to their expectation in these kinds of societies zizek avers the subject advocates freedom or equality while being unaware of implicit qualifications which in their very form constrain its scope for instance in the short story people blindly adhere to societys rules without considering the constraints imposed by those rules in fact they have to first accept the fact that there is not going to be an equal society zizek also asserts that there are numerous ways to sell unfreedom to ideological subjects as absolute freedom we are told that when universal healthcare is withdrawn we will have new freedom of choice in the case of bergerons family they are deprived of fundamental freedom such as the ability to make their own choices but the guarantee of equality encourages them to embrace the circumstance and regard their lack of freedom as absolute freedom in player piano the characters are made to believe that the big other of the society a role occupied by the elites is going to provide them with a prosperous future in fact the big other provides the political subject with that the subject has authentic freedom according to this statement the presence of an external other can create an environment in which one can experience true freedom in both the short story and the novel the big other can also be considered as the oppressive government enforcing equality through technology in harrison bergeron for instance the handicapper general limits individuals by suppressing their natural abilities and talents to maintain a superficial sense of equality in addition corporations and governments manipulate rules in order to maintain their dominance and accumulate power it is in such a suppressive context that an alternative space a space of liberation is possible this emancipatory space is digitalization and the process of dehumanization digitalization is considered a powerful tool for manipulating thoughts of the characters in the story through utilizing technology the ruling authority controls the equalitydriven society technology and human agency in kurt vonneguts harrison bergeron and player piano international journal of language and literary studies 324 for instance as harrison bergeron begins the narrator touches upon the fact that george while his intelligence was way above normal had a little mental handicap radio in his ear he was required by law to wear it at all times despite the short storys emphasis on the negative consequences of extreme societal control it can be argued that there are potential benefits as well for instance by using technology to enforce equality they want to eliminate any kind of discrimination in society but in practice they are not very successful due to equality purposes the government also does not let anybody dominate other people which also encourages collective intelligence all in all the ideas are certainly useful theoretically but not practically in the said short story being handicapped influences georges life throughout the narrative for instance when he and hazel are watching television his train of thought about the beauty of ballerinas is halted a buzzer sounded in georges head as a result he is unable to engage in critical thinking the limitation applies not only to george but to all of the aboveaverage intelligent people in society in this scene vonnegut illustrates how authority figures exploit technology to control their subjects for instance when george and hazel were watching television suddenly there were tears and hazel totally forgot about the reason behind it due to the buzzers in georges head he cannot remember his thoughts the devices are technological apparatuses that manipulate and control the characters actions and minds which can be regarded as a form of digitalization in order to maintain the principle of equality the handicapped must adhere to strict guidelines conversely in player piano the reader faces a society where machines have largely replaced humans causing a significant gap between elites and a rapidly disappearing working class in this society most people are considered useless due to the digital revolution tally in his critical works on vonnegut avers that at issue in player piano as vonnegut makes clear throughout the novel is what happens to the soul of man in the world of machines but vonnegut frequently blurs the lines between man and machine showing not just how humans are being replaced by machines or how machines have dehumanized american society in player piano the reader comes across the notion of digitalization directly bloom also in his critical work on vonnegut contends that player piano belongs to the formulaic tradition of the antiutopian or dystopian novel that it is concerned with the threatening replacement of men by machines moreover the danger of machines for future generations and the dehumanization of human beings are the most prevailing themes in this novel besides even the engineers themselves who are considered the members of the elite group are displaced from their jobs as in the part where bud is talking to proteus about how he missed his occupation what about the gadget you invented for thets it said bud with an eerie mixture of pride and remorse works does a fine job he smiled sheepishly does it a whole lot better than ah did it in this section it becomes evident that bud one of the educated elite is displaced from his job due to his own invention a machine that surpasses his own abilities in terms of efficiency and performance zizek also states in his interview with rt that despite technological surveillance encompassing every aspect of their lives individuals continue to perceive themselves as autonomous beings within society regarding the neuralink project by musk zizek argues that it is a company which is focused on creating devices that can be implanted in the human brain with the eventual purpose of helping human beings it means at first they try to introduce their new plans as very helpful similarly in the story the government pretends to be of great assistance to the populace by advocating for equality but in reality this is not the true intention in the novel a web of societal manipulation and advanced technology promises illusory results for those at risk of displacement the elites those in positions of power and influence try to lure people into embracing the notion that technology will liberate them from their daily struggles and make their lives easier however buried beneath this veneer of innovation lies a devastating truth that is advanced technology has ultimately resulted in the displacement of workers especially among the elderly and illiterate furthermore the very technology that society relies upon to improve lives is aggravating the socioeconomic divide the sinister motive is to get access to peoples thoughts in order to physically and psychologically enslave them the majority of our activities are now recorded in some digital cloud that permanently tracks our actions as well as our emotions this is what it means to be free in harrison bergeron the handicapper general has complete influence over the actions and feelings of the characters this is evident when hazel watches her son die on television and she cries for a brief moment but after that she forgets the reason for her grief therefore the ruling authority effectively controls their thoughts actions and potential by altering their physical and mental capacities furthermore as zizek expresses in his interview with rt news the more technology makes progress the more class divisions will appear he believes that the rapid progress of technology divides society into different socioeconomic groups according to their wealth and intelligence this observation highlights how technology has become a tool for social control causing social hierarchy this class division is not limited only to the people in society technology and human agency in kurt vonneguts harrison bergeron and player piano international journal of language and literary studies in hegel in a wired brain zizek gives rise to a fundamental question regarding technology which is what will happen to society politics and daily life when nonconscious but highly intelligent algorithms know us better than we know ourselves in raising this question he tries to express his concerns regarding the time when machines will be superior to human beings this issue can be traced in player piano in which the elite group is responsible for controlling the whole country after the world war that has gripped the society further clarifying the issue zizek then goes on to aver that most humans will not be upgraded and they will consequently become an inferior caste dominated by both computer algorithms and the new superhumans in this statement zizek is trying to underscore the fact that with the advancement of machines we are not able to be the decisionmakers and therefore we will be wholly dominated by machines in accordance with what happens in player piano zizek here avers that if a group of people called the elite or anything else regard themselves as superior to the ordinary people in society they will probably make the most important decisions in that community for instance kroner in player piano is one of the rulers of the country who leads the engineers in the direction that the government wants he is also a highranking official and the ruler of the eastern division he is an avid fan of technology and automation regardless of the concomitant side effects that rack other peoples lives it is of utmost importance to quote the conversation between kroner and proteus regarding the power of technology you will find that a steelmill motor will do more work than the entire slave population if you convert its horsepower into manpower as it is evident in the abovecited passage kroner as a highranking official has a condescending view towards the ordinary people in society since he is highly powerful in this technological society he considers the entire population as slaves as they have to act according to the elites decisions likewise in dharrison bergeron the enforcement of equality by virtue of technology creates a clear division between the ruling class represented by the handicapper general and the oppressed characters who have been stripped of their individuality and abilities by suppressing any signs of superiority and enforcing mediocrity the ruling class maintains control over the ordinary people on the one hand ordinary people are being handicapped through various technological means such as radio transmitters conversely there are authorities bearing no handicaps therefore the technology in this story leads merely to the limitation of characters such as george hazel and harrison that is why zizek avers that it is absolutely imperative to keep it out of the control of private capital and state power and to render it totally accessible to public debate due to technological advancements society can be further divided into different social groups based on their advantages or disadvantages in the story it can be inferred that the handicapper general bears no handicaps herself and the society is divided between those who rule the society and those who are the puppets of the governments decisions the laws imposed by handicaps give privileged positions to those with advanced technology such as diana moon glampers while those without advanced technology are marginalized diana glampers does not wear handicaps herself and her role is to disable the characters with aboveaverage abilities in the story not only power is in the hands of the handicapper general but also technology is completely in her control from digitalization and digital control in general we move to the more specific project of the wired brain this is also what vonnegut tries to render through the theme of government control he warns how technology can be considered a means of monitoring and regulating peoples behavior using radio transmitters the government reminds citizens about their restrictions prevents them from getting too involved in certain topics and discourages them from questioning policies likewise in player piano it is also evident that advanced technology has caused class division in society as evident in the following quote ilium new york is divided into three parts in the northwest are the managers and engineers and civil servants and a few professional people in the northeast are the machines and in the south across the iroquois river is the area known locally as homestead where almost all of the people live in the said novel two major classes exist in society the managers the engineers who control the machines and the reeks and wrecks the displaced working class those in the management and engineering sector are considered as the upper class enjoying the privileges and benefits that accrue to them due to their high social standing they live in sophisticated communities called garden cities and everything is available for them and their families conversely the workers who constitute the large majority of the population have been rendered obsolete by automation they constantly deal with finding meaningful work to do since machines perform their tasks much better they are largely gripped by dissatisfaction frustration and resentment as they tend to do menial jobs or else are unemployed the effects of new technology are not only limited to unemployment human minds are becoming increasingly connected with technology as a consequence of the wired brain in this process the human brain is linked to digital networks or implants are installed that enhance in the abovementioned short story even the essence of humanity is conquered the technology we all believe will provide benefits to us is being used as a means of punishment for the people in society sounded like somebody hitting a milk bottle with a ball peen hammer a loud noise in georges head interrupts him as he ponders the idea that ballerinas dancing on the television show should not be handicapped as it takes their beauty away therefore george is nothing more than a living robot in this story this scene portrays not only a moment of chaos but also how technology which is in grasp of those in authority plays a major role in the dehumanization of the characters examining the scene in light of zizeks ideas on digitalization it can be inferred that vonnegut by using the metaphor wanted to warn the reader about the repercussions that advanced technology has in store for individuals similarly in harrison bergeron the noise of somebody hitting a milk bottle with a ballpeen hammer characterizes an abrupt intrusion disrupting the socalled equal society depicted in the story as zizek avers today a new era of slavery is arising what we witness is also slavery through technological means in a fictionalized world in which equality is taken to an absurd level therefore based on the foregoing critical discussion it is imperative to reconsider our relationship with digital devices since while it is believed that they are going be helpful they can result in the loss of our agency as exemplified in harrison bergeron and the novel player piano loss of human agency given that recent studies on technology and its effect on human agency have demonstrated that technology can erode individuality the utilization of technological means such as radio transmitters to reinforce government ideology comes to the fore in the thematic analysis of the short story and the novel human agency in literature refers to how characters make choices and take actions that affect the course of their lives and the plot throughout sublime zizek defines human agency as the subject itself is the abrogatedcleansed substance a substance reduced to the void of the empty form of selfrelating negativity the concluding section of this study illuminates the notion that employing technology to govern and manipulate human behavior undermines the capacity to think independently and make informed decisions rooted in personal beliefs to begin with in the story the reader is immediately introduced to george and hazel a couple grappling with constraints enforced by a dystopian society that rigidly upholds absolute equality when the narrator describes george and hazels inability to think about their incarcerated son who is in jail at the onset of the story the reader becomes curious to find out why they react so indifferently put differently it provokes the readers curiosity compelling them to unpack the reason behind this weird limitation it was tragic all right but george and hazel couldnt think about it very hard as we delve into the story it becomes evident that vonnegut aims to convey the undermining of characters agency through decentralization the government employs technological means to impose its ideology on the characters allowing the highranking officials to effortlessly control the thoughts and actions of ordinary people technology serves as the primary tool for control it takes the form of physical handicaps imposed on individuals to suppress their natural abilities for example the storys protagonist harrison bergeron possesses exceptional intelligence and attractiveness his disadvantages are offset by heavyweights distracting earpieces and glasses that hinder his vision such handicaps prevent him from expressing his true potential forcing him to conform to social norms in the novel player piano the loss of human agency is a central theme that examines the repercussions of a highly automated society in which most citizens are deprived of having a simple job since machines have taken over most jobs thus rendering humans obsolete in the workforce in this socalled utopian world machines and computers have become so sophisticated that they can perform every task much more efficiently than humans leading to a society where people have no job and purpose even the character called shah who has come to the us in order to explore new technology and culture addresses the ordinary people as slaves he would like please to know who owns these slaves we see all the way up from new york city shah here illuminates the fact that technology has transformed people in society into slaves the socalled slaves in this novel have been replaced by machines in a way that technological devices can change everything in their lives thus they have no power to express what they want and even when they rebel against technology it is not successful as they once again come to rely on the technology they had rebelled against one of zizeks key concerns is the correlation between technology and human agency in examining the progressive process of technology and government he explores how technology throughout sublime particularly in the first chapter he subtly argues that individuals living in society are not more than passive victims of the prevailing ideology in addition they actively contribute to its perpetuation by pointing out the repercussions of lawbreaking or not temporarily disabling their handicaps for instance the character george repeatedly alerts hazel about the repercussions of not abiding by the laws when i try to get away with it other people would try to do the same and wed all be back in the dark ages again in fact zizek emphasizes how social structures affect an ideological subjects involvement ultimately leading to the loss of agency even though george and hazel actively reinforce ideology their agency is often limited by the ideological framework shaping their beliefs and behaviors the transmitter would send out sharp noises every twenty seconds or so to prevent people like george from abusing their brains in player piano we face the ghost shirt society who rebel against the engineers and technology itself they indeed rebelled against the machines since there was a reversal between man and machines but they were not successful in the end because they even destroyed the machines they needed themselves therefore they backed to machines whom they fomented a revolution for david simmons in his book new critical essays on kurt vonnegut touches upon the fact that paul proteus and a group of rebels drink not to success nor even to failure but simply to the record and the final words of the novel are forward march zizek also avers immersion in singularity is just the first option the second option if machines win then humans are in danger of losing their value because intelligence is decoupling from consciousness here it is clear that zizek is directly referring the likewise in harrison bergeron the narrator asserts that everybody was finally equal however this forcefeeding equality comes at the cost of losing their agency hazel had average intelligence which meant she could only think in short bursts on the other hand george had aboveaverage intelligence but had a mental handicap radio in his ear which he was required by law to wear at all times in the first chapter of disparities zizek observes that new technologies have a major impact on the way we interact with ideologies today furthermore he argues that technology functions as an ideological supplement reinforcing existing ideologies and impeding critical thinking the short story presents a similar scenario where the reader encounters this situation due to his aboveaverage intelligence george is handicapped and unable to engage in critical thought consequently technology has bolstered the ideology of diana moon glampers stripping individuals of their autonomy and freedom the rest of harrisons appearance was halloween and hardware handicaps nobody had ever borne heavier he had outgrown hindrances faster than the hg men could think them up therefore technology limits harrisons agency and prevents him from exercising his talents and abilities by creating new forms of power and domination regarding the concept of digital space and agency zizek argues that we are finding ourselves moving closer toward automation resulting in various forms of digitalization in both the short story and the novel we can trace clear manifestations of dehumanization particularly through the governments implementation of handicaps to enforce equality among its citizens and the utilization of technological machines instead of human beings at the cost of displacing them from their jobs in harrison bergeron the effects of dehumanization are evident not only in harrison but also in other characters such as ballerinas the ballerinas in the story exemplify how this societys obsession with equality devalues human qualities despite being beautiful graceful and exceptionally talented in their craft they are compelled to wear weights and masks that hinder their natural abilities in the hope of maintaining equality by suppressing their advantages over others these handicaps are to eliminate diversity and creativity they are also obligated to wear masks to hide their natural beauty similarly musicians find their natural rhythms disrupted by the intrusion of technological devices as a result george and harrison are deprived of their agency though intended to enforce equality zizek also asserts that it is surprising that my body is not mine anymore and that mind control machines are robbing us of our agency he then goes on to say that the body is yours but you this is exactly what happens in the short story because of the handicaps imposed on the characters they cannot control their bodiesfurthermore the government which seeks absolute equality limits and restrains them for instance george thinks he is directing his own body but technological devices are controlling him what exacerbates the situation in both the story and the novel is that technological machines are controlled by authorities technology plays a major role in reinforcing these oppressive measures through using sophisticated devices diana moon glampers the handicapper general in harrison bergeron monitors and takes control of every action of the characters this kind of heavy reliance on technological devices not only stifles individuality but also refrains the characters from genuine human connections similarly in player piano everything is controlled by machines with the elites being the governments agents as a result the characters potential is subordinated to the demands of the system one of the considerable advantages of kurt vonneguts oeuvre therefore is that he was totally aware of the changes happening in his era due to the advancement of technology which reveals he was conscious about how the nature of human beings was altered in the context of the society portrayed in this story people believe they are autonomous subjects making their own choices humans are in danger of losing their value because intelligence is decoupling from consciousness as one can observe in the short story the characters george and hazel lack the autonomy to choose their own thoughts if hazel hadnt been able to come up with an answer to this question george couldnt have supplied one a siren was going off in his head but at the same time we are more and more determined by economic and even military processes that are impenetrable agency is taken from us zizek offers an analysis of how we are controlled by various means such as technological devices or ideology and how those in power rob us of our agency he then notes that nobody wants to know how much they are controlled and to what extent they are allowed to make decisions since they have already adapted themselves to the situation this is what occurs in harrison bergeron i dont mind it he said i dont notice it any more its just a part of me as zizek avers in his interview with new internationalists by virtue of technology government officials strip us of our subjectivity and agency as soon as they dominate our brains here again we can refer back to the concept of belief in ideological subjects volume 5 issue 3 2023 as mentioned before harrison bergeron stands as the sole embodiment of agency amidst an ideological society through his actions in the final parts of the story he defies the established norms to assert his agency although his rebellion is tragically shortlived as diana moon glampers kills him it serves as a powerful instance of how the human spirit can challenge dominant ideologies in player piano the reader also faces a rebellion against automation the rebel at the end of the novel player piano is a character named paul proteus throughout the novel paul is shown as a sophisticated engineer at the ilium works paul begins to question the role of technology and its impact on human existence as the story progresses becoming disillusioned with the mechanized society in which he lives as people lose their purpose and identity in a machinedominated society he witnesses the dehumanization of people consequently he joins a secret underground movement called the ghost shirt society which aims to restore meaning to human life by resisting the oppressive system the ending of player piano presents a complicated moral dilemma as paul realizes he has not only challenged the machines authority but has also caused suffering and displacement to those who depend on the system conclusion in conclusion this paper highlighted the intricate correlation between technology and ideology in shaping the fundamental structures of society it is of utmost importance for individuals to be aware of the growing dependence on advanced technology and the inherent risks associated with it by emphasizing the fact that technological devices can be a means of both government control and ideological imposition this study broadens the readers horizons regarding the potential risks and challenges associated with the growing dependence on advanced technology it also illustrates the dehumanizing effects of technology when used as a tool for imposing ideology depicting how technology erodes the agency of the public in society and how it can result in job displacement slavoj zizek the primary theorist of the current study addresses the profound impact of technology and ideology on human agency through his theories regarding technology and government control he attempts to provide critical insight for the readers likewise in the story kurt vonnegut illustrates the influence of advanced technology on society during his time vonnegut by criticizing and satirizing the dystopian society of both player piano and harrison bergeron portrays how technology is utilized by the government agents as a modus operandi for both imposing its ideology and controlling people consequently the handicapper general in the short story and the elites in the novel as the government agents turn people into robotic beings who abide by all social rules according to the argument that has been furnished so far it is also of overarching importance for readers to engage in selfreflection and examine their relationship with technology the readers must critically question the ideologies embedded in technologies controlled by those in power and thus be cognizant of the repercussions emanating from them thus what vonnegut tries to express throughout these two precious works of art is that one must not be treated as a technological machine since human beings are more valuable moreover one should respect their own agency identity and dignity to as to deliver themselves from such socalled utopian societies ultimately this paper set out to achieve its threefold objectives firstly the paper explored how ideological subjects consider their unfreedom as freedom as explained in light of zizeks theory of freedom secondly it delved into the dehumanizing effect of technology when employed as a means of ideology finally it examined the erosion of agency within a technologically advanced society where the government agents utilize technology to exert control over its citizens conflicts of interest i declare no potential conflict of interest

technology and ideology are intertwined in shaping the dynamics of power and control within society the relationship is especially evident in technological advancements where novel innovations have the potential to take control of ones mind and actions we have become increasingly dependent on advanced technology in recent years providing us with convenience and efficiency unlike ever before it is however important to recognize the risks and challenges associated with this growing dependence

introduction the pandemic caused by the uncontrolled advance of coronavirus disease 2019 reached brazil in march 2020 demanding quick responses from autochthonous transmission identification this scenario highlighted the need to offer subsidies to students in the health field especially those in advanced training stages for safe assistance without losing sight of the quality of teaching in this context there are graduate students in supervised curricular internship and nursing residents in different professional training programs anchored in inservice teaching for which the adoption of social isolation measures coincided with the beginning of activities in the first academic semester mainly in the state of rio de janeiro considering the impossibility of maintaining academic activities it became imperative to critically reflect on the practical training of undergraduate students and residents of health institutions it is understood that the aggregation of theoretical and practical knowledge is essential for developing attitudes skills and competences necessary for safe care for students and users in this regard it is understood that the current epidemiological overview constitutes a limitation for formal classroom teaching however distance learning appears as a viable strategy as it is a modality of teaching and learning in which educator and student do not share the same physical space or chronological moment in all or part of the learning path having its heart in interactive relationships through a telecommunication process developing a dl course on coping with covid19 was envisaged in order to enhance the sharing of experiences among peers combat fake news develop citizen awareness and build nonformal education actions within possibilities of the current context thus the management of training is registered in a nursing faculty of a public university located in the city of rio de janeiro the course design followed the theoretical concept of teaching virtualization which considers the virtual environment as a fertile space for generating and updating knowledge combining the creative potential of participants with the nomadic aspect of temporal and geographical abstention to materialize the educational process making it real despite not being in site under this perspective the course organization was based on problematization as a central axis to build knowledge through pedagogical mediations in a virtual learning environment experiences about using technological resources to implement dl activities especially for noncurricular purposes such as those aimed at professional qualification are encouraged by the federal nursing council moreover a database survey conducted in april 2020 using the boolean phrase distance learning and nursing students and training found 114 results of which only three publications were from national experiences considering the gap existing in the construction and socialization of brazilian initiatives on vle use in nursing sharing successful experiences is necessary especially in atypical scenarios such as the current pandemic which require rapid training of nursing professionals imposing limitations for develop classroom teaching practices objective to report the experience of developing pedagogical mediations in a vle implemented in a nursing faculty during the covid19 pandemic methods this is an experience report with a descriptive approach on the development of emergency nonformal education actions for graduates and residents of a nursing faculty at a public university located in the city of rio de janeiro the experience took place between march and april 2020 with organizational activities carried out entirely through digital technologies aiming at bringing students and professors closer to the emerging theme in public health undergraduate teaching coordination created the coping with covid19 course in the form of an introductory nonformal education project in vle the course was conceived operated and offered as free and autonomous participation without obligation or attribution to any administrative work or formal teaching process using vles modular objectoriented dynamic learning environment software linked to the universitys undergraduate deans office the course was structured in three thematic blocks these blocks contained didactic materials and activities oriented by problematization associating diverse forms of content presentation with pedagogical mediations totaling a workload of 30 hours from conception to implementation of the course it was an intense journey that encompassed many comings and goings it was up to utg to mobilize a group of 44 professors who were willing to collaborate in the operationalization organizing it in three teams central working group composed of 15 professors and two nurses linked to the universitys assistance units responsible for the construction of teaching materials mentoring group with 27 professors involved in the mediation process in vle technical and pedagogical support group with four professors who wove the projects structure and monitored its development implemented on 03272020 the courses initial offer had a target audience of 279 students of which 229 had records of access and participation in vle with 54 interns from the last year of nursing undergraduate and 176 resident nurses from the first and second year of the institutions nursing residency programs moreover 17 professors expressed interest in participating as listeners and were brought together in a single group without tutoring pedagogical mediation this article did not require evaluation by a research ethics committee as it did not involve participants in an investigation or intervention results the experience followed the path proposed by the instructional design in online education and its report was divided into three moments the conception of the coping with covid19 course from operationalization to implementation of the course the sum of efforts the technical and pedagogical support groups view on the educational proposal of pedagogical mediations for nonformal nursing teaching during the covid19 pandemic prata ja mello as costa e silva fv faria mga conception of the coping with covid19 course the first moment of this experience consisted of planning the course which began by identifying the emergency demands for specific learning about the pandemic the target audience and the objectives to be achieved it culminated in the understanding that the course would be a nonformal teaching activity this modality involves sharing experiences and collective discussion in everyday spaces not necessarily institutional as educational processes that articulate values cultures and subjectivities to awaken a critical eye on a context in which educational action is circumscribed with a view to promoting citizenship of agents involved and transforming the reality in which they are inserted although there was a need for virtualization of the course due to social isolation the next step was to elaborate a pedagogical architecture to materialize it as a problematic open spontaneous teaching and learning process with free and continuous access to information built from virtual interactions and collective reflections on facts objects and people in the context of covid19 therefore in opposition to the content logic commonly adopted by most educational resources available in the virtual environment the course proposed to use didactic materials and was based on pedagogical mediations between tutors and students to encourage specific knowledge exploration about covid19 and provide an exchange of experiences thus it was possible to collaboratively build knowledge and solidarity from a dialogical and problematizing perspective which would pave the way for critical and reflective action of health action from operationalization to implementation of the course the sum of efforts the second part of this experience was dedicated to fundraising preparation of teaching materials definition of forms of interaction appropriation of technological means and specific technical processes related to the course preparation and organization in vle a phase that included registration training and setting of professors and students this process took place over a period of 10 days which required a collective work on multiple fronts conducted by the technical and pedagogical support group which sought potential collaborators who had an approximation with the contents listed for the thematic blocks and previous experience in vle use reaching 44 teaching partnerships under the coordination of two professors the teaching materials for each block were produced by the central working group which streamlined the search and construction of activities for an introductory theme exploration with support of tutors in this regard the group developed didactic strategies widely used in virtual environments such as video classes educational and artistic videos images poems texts with verbal and nonverbal language reports articles and technicalscientific documents they were made available in association with different activities that trigger discussions and reflections in forums and chats 10 as a result of the work of this group the thematic blocks had a new configuration the first and second being divided into three parts and the third distributed in five as shown in chart 1 as part of the course operationalization the technical and pedagogical support group was dedicated to organizing the set of teaching materials in vle this activity lasted for about three days and was carried out entirely by nursing professors which demonstrates the feasibility of courses of this nature being built by nursing even in the absence of specific training for this purpose subsequently the mentoring group responsible for pedagogical mediation between students and materials in vle was invited for a brief training and setting of tutors in which they became familiar with the lesson plans of each thematic block in vle for two days this initiative was essential considering that many tutors were insecure with little appropriation of the emerging theme and in many cases because it represents a first approach to nonformal teaching and the use of digital resources for pedagogical purposes in addition to these training dynamics we opted for organizing tutoring in pairs of professors with different nursing specialties one with expertise in primary care and the other in hospital care with the aim of qualifying the mediation process another resource employed was the creation of a direct communication channel between the mentoring group members through a messaging application based on interactive relationships that use telecommunication and problematization the course pedagogical architecture was designed with the purpose of constituting dialogic spaces conducive to sharing knowledge and experiences in a horizon of qualification of care practices of those who are in the services it also aimed at offering educational and sensitive care amidst the pandemic aimed at the dissemination of appropriate community guidelines and the promotion of mental health in the context of social isolation subsequently it was decided that the course would be organized in three thematic blocks dealing with relevant contents of the pandemic context combined with the scope of nursing practices epidemiological overview clinical and care management complications and specificities to guide the construction of teaching materials a lesson plan model was created containing the following information thematic block title of the activity theme addressed objective to be achieved activity length for students and tutors pedagogical strategy what is expected from students and tutors related materials and complementary bibliographies it is noteworthy that this strategy also aimed to ensure a certain uniformity and fluidity between the different activities of the thematic blocks of the course and to watch over the pedagogical process based on problematization that guides the institutions curriculum even when teaching practices develop virtually these strategies brought professors closer together and formed spaces for permanent education for tutors which made it possible to share specific knowledge from covid19 and experiences on the interaction with students and the use of digital tools throughout the course furthermore it provided a space of care through sensitive listening and welcoming the experiences of suffering in the context of the pandemic at the same time utg collected data on nursing interns and residents in order to streamline the process of enrolling and distributing students in a vle students were divided into 11 virtual classes respecting the ratio of a maximum of 25 students for each 2 tutors this allowed establishing welcoming and empathic relationships as well as favoring the organic construction of knowledge about the emerging theme of covid19 in dialogue with the empathy essential to the context lived from which sufferings concerns anxieties losses and singular ways of coping with social distancing emerge especially from university life we resort to lovingly teaching pedagogical action in welcoming students in a vle in this sense a video was built accompanied by a welcome message in order to soften the technical nature of the theme and the apparently harsh perspective of digital information and communication technologies the technical and pedagogical support groups view on the educational proposal as an essential part of the entire teaching and learning process the technical and pedagogical support group was in charge of monitoring and assessing the course from its implementation on march 27 until its completion on april 10 2020 during the educational proposal it was identified the need to extend the course length for another four days since 176 students were nursing residents who worked on the front line of coping with covid19 they found limitations to participate in the proposed daily activities due to the workday as well as physical and psychological exhaustion due to assistance in the current scenario of the unified health system in conditions that are often strenuous and precarious in terms of material and human resources despite not being mandatory it is understood that the course had a good adhesion even though experiences of suffering and difficulties in accessing the internet may have been configured as limiting factors for the participation of a small group of students this perception is based on significant material exploitation made available and interaction with tutors by 229 students of a total of 279 enrolled in spite of these notes it was possible to notice that the sharing of experiences between students residents and tutors offered the dialogical basis and the kindness necessary for sensitive reception and the development of citizen awareness likewise the exchange of information has brought support to a discursive practice capable of deflating with consistent arguments the flood of fake news that has flooded social networks study limitations considering that this educational experience is related to an emergency and atypical context of brazilian public health its development faced time as a limiting factor of the potential that the course offered thus it had repercussions in absence of prior consultation with students on internet access difficulties in accessing the course with smartphones insufficient disclosure damage to better use by students another limiting factor was lack of proximity to the functionalities of vle which led to underutilization of its resources by all involved contributions to nursing health and public policies the present experience subsidized reflections about vle activities as a complementary resource to teaching in nursing when developed from a problematic perspective and through intentional pedagogical mediations in this perspective the potential of teaching virtualization pointed out in this experience brings contributions to public policies they establish a new perspective on dl for the training of human resources in health particularly in nonformal and continuing education activities demystifying the common sense about this modality and the lack of technical knowledge as a limiting factor for its implementation final considerations as academic activities were suspended due to the pandemic the present report experience was considered an efficient organic strategy that promoted collaborative learning of knowledge about covid19 and strengthened the relations between professors and students even in times of social isolation furthermore from the perspective of pedagogical practices the professors saw the potential of using vle through • highlight epidemiological aspects conceptual approaches and ethical issues that involve the nature of a pandemic event clinical and care management 3 days • present a set of techniques and procedures of nursing practice in direct care for symptomatic or confirmed patients discuss infection control measures and the health of health workers in the context of covid19 • know the clinical management of respiratory syndromes complications and specificities 4 days • identify situations of worsening of the disease know care protocols in intensive care units • discuss care for special groups affected by covid19 • reflect on the ethical and bioethical aspects of health care in the pandemic scenario technological mediations based on problematization contrary to the content logic often observed in dl therefore it is believed that this experience of nonformal education functioned as an experimentation that provided the acquisition of essential knowledge to plan formal education in a future return to university life which will face challenges in person considering covid19s epidemiological characteristics and the structural weaknesses of universities in brazil on the other hand even though digital accessibility may have represented a limitation for some students the high percentage of access to the course reveals the possibility of implementing distance activities for theoretical and theoreticalpractical teaching in nursing this occurs considering the probable health need for adopting a hybrid teaching and learning process through inclusive actions that favor participation of all and safeguarding the essentiality of classroom teaching for nurses practical training

objective to report the experience of developing pedagogical mediations in a virtual learning environment implemented in a nursing faculty during the covid19 pandemic methods an experience report on the construction of a distance course aimed at graduates and residents of a nursing faculty at a public university located in the city of rio de janeiro results the courses conception operationalization and implementation were the result of a collective work that culminated in a nonformal virtual and problematic teaching process which reached a participation rate of 82 of enrolled students final considerations even in times of social isolation the course promoted collaborative learning of knowledge about covid19 and strengthened the relationship between professors and students the possibility of carrying out distance activities based on solid methodological proposals that contradict the content logic often observed in distance learning is emphasized

introduction the present article has used ethnography to make participant observations in six local neighbourhood schools in rural parts of sweden together with interviews and the collection of local documents it shows three things in particular that also relate to how rural education is described in other european educational research these are firstly how rural communities and their schools are very different to eachother and are differently positioned and affected by national education policies secondly what the visible effects of this seem to be on schools education and educational experiences motivations and behaviour in local communities thirdly what the possible policy implications of this can be for a more generative theory and politics of rural schooling today the presentations of ruralities and rural education to a degree lacks subtle nuances that we try to address in this article by employing three different research corrections the first correction is one that addresses a key imbalance in rural and urban research on education and youth experiences it departs from the recognition that although there are many investigations about urban youth and their social involvement and marginalisation in education and wider society research on rural youth is scarce there is a prevalent focus on urbanities based on what farrugia describes as an unacknowledged metrocentricity the second addressed imbalance is that perhaps because of this notions of rurality and rural education tend to be uniform abstract and rather simplistic within society as it is today spaces form clearly distinct realities and individuals construct their identities in relation to the different possibilities and contexts for inclusion social participation and agency that these places provide educational politics seem to currently deny rural populations this kind of recognition of the rights and possibilities of active agency with this corresponding to the third point of imbalance we try to address this is the passivity that is often accorded toward rural spaces and their agents and the passive object status that is often given to the concept of rurality we agree with corbett when he states that rural schools can and should be politically discoursed and expressed in educational policy and practice as places where the complex work that deals with local and specific rural problems is done but that this kind of recognition is not what characterizes present educational policy making in the article we will thus attempt to showcase the different conditions that can characterize rural places and their schools when doing so we attempt to address what is meant and understood by the concept of rurality in education and rural education policy we bind these perspectives together with the help of an analytical understanding of space in accordance with massey and lefebvre and metrocentricity from the work of farrugia we identify how education policy works through different rural areas differently and we do battle like bagley and hillyard and corbett against a uniform image of the countryside with roots that are identified from urban research and notions of a problematic marginalized youth from passive and poor environments who lead deprived lives what we identify is is far from passivity and deprivation we recognize instead how place is actively attended to in some respect in every rural school in our research but it is also attended to differently as the different places provide different possibilities and contexts for addressing the local community from in education not the least due to the predominat economic conditions and production relations and the burgeoning globalization of a specific form of capitalism and economic production with new conceptualizations of margins and centers of influence and power this is the era of finance capital it is a state of empire according to hardt and negri of relevance for everything including global educational politics and conditions as well as research on rurality and links between identity context and education in this sense this is also our main address later in the article thus although they are raely given much attention in rural educational research globalization and the organization of economic production in the age of empire have had significant effects on rural communities and their schools as they have affected the aspects of the local that are available to and selected for inclusion in teaching and learning content this theory theoretically the project draws on materialist spatial geographic theory as represented in the work of doreen massey where space is understood as continuously in process and shaped through sociospatial and material practices in forms of interaction that both produce and contextualise the relations of production and historical social relations there is a close connection between space place and the construction of social relations and spatial identities from this theoretical position rurality is a transformative signifier in our research not a passive object ruralities and experiences and understandings of them are capable of changing teacher and pupil behaviour and affecting education motivation and performances and any research or theory of rurality in education needs to take this into account in its attempts to ground ideas about a ruralplaceconscious education and its possible and actual roles in and relationships to rural life such place conscious theories of education are rare but they are also of greater value to educational stakeholders including teachers pupils their parents local businesses and educational politicians and policymakers as corbett has suggested education is as significant in and to local lives as is labour or production and as are community and production relations it and experiences and understandings of it are formed in concrete space and time contexts a certain place at a certain time shows a particular mix of social relations but the identity of a place is meaningful according to massey and lefebvre also in the sense of it largely deriving from the specificity of its interactions with spaces outside as massey and others such as chandler point out the growth of industrial capitalism saw the massive reorganisation of vast areas in rural spaces in europe with this creating pockets of semiand periurban industrialisation and settlement in these areas yet at the same time other areas were left relatively untouched by industrialisation and there settlements remained quite sparse there thus the effects on rural areas on rural areas vary between being centrifugal and centripetal forces ie either pushing populations out of a rural area or drawing them in depending on assumed economic needs and current economic climate education relations in local communities are formed at least in part in relation to the conditions of economic and cultural production the convictions of value that agents generate and the push vs pull forces they may exact rural spaces are depicted as simple but they are in fact complex and multilayered social constructions in respect to which understandings of local educational needs and possibilities and their manifestation in educational policy and practice are dialectically related this can also be seen through previous research for instance research shows youth in marginalised poor urban areas to describe their neighbourhood in contrast to the more prestigeous wealthy areas and there are indications that hegemonic understandings of urban living appear to be vital for the identity constructions made by rural youth concerning for example understandings what a good life is which in turn has implications for young peoples thoughts about their future and chances of social inclusion and influence now and in the future research sites researched schools and their location there are many different forms of rurality and to avoid stereotyping rurality as one category we chose to include both sparsely populated areas tourist municipalities and small industrial communities from different parts of sweden in our research these locations each represent an official category in formal definitions of rural palces within them sweden is currently politically divided into 290 municipalities and 20 counties one of the main towns in the municipality will be its seat and the site of the municipal offices the six schools selected for the study were chosen to provide a variation in terms of area location in the north or south of the country distance to the municipal seat and classifications of the local labour market the characteristics of the schools and their municipalities is shown in table 1 below table 1 about here all the researched schools come from one of three broad types of area and all of them except forest and river school were the only secondary schools in their municipality the areas are intermediate rural areas with diversified employment situated at some distance from urban centers or having some moderate difficulties of access to them and having lowtomedium income levels in primary secondary and tertiary sectors periurban rural areas with an increasing population and a predominance of employment in the tertiary sector with mediumtohigh income levels and sparely populated areas with small settlements and lower economic activities that are principally confined to the primary sector and sometimes tourism methodology the chosen methodology for this research was ethnography ethnography focuses on the study of cultural formation and maintenance in particular places through multiple methods for the generation of diverse forms of data based on the direct involvement and longterm engagement of the researcher as the main research instrument the intention is to provide accounts of how the everyday practices of those engaged in educational processes are implicated in broader social relations and cultural production and to highlight the agency of educational subjects in these processes five weeks of continuous fieldwork was planned for one class from each school to these ends to be carried out by three individual researchers in 20152016 one at each site with occasional visits from others in the research team temporally compressing fieldwork in this way is one of several ways of using research time ethnographically however being able to accommodate five consecutive weeks in the field at each site was in the end found to be problematic due to other commodified labour at their different workplaces the three field researchers were not able to accomplish five consecutive weeks of fieldwork and three to five one to two week visits were carried out at each site instead as jeffrey and troman write this represents and intermittent time mode it is meant to allow a flexible approach to the frequency of site visits and progressive focusing in relation to the participant observation and general data production it involves the development and continual evaluation of a characteristic ethnographic spiral of research planning and reflection data production and analysis new planning and further data production and analysis along the lines of the collective ethnography developed by tuula gordon and associates it involved the team members doing the following • reading each individual researchers fieldwork narratives carefully to identify the main concepts and ideas and their possible relationships and general implications • checking the relevance of the concepts within the scope of the project • identifying patterns in the field terms of the cultural processes that may be evident in our collective ethnography each individual project researcher has thus concentrated on her or his designated research site but the investigations are also strongly jointly planned and collective discussions are used as a means to help to develop reflexive interpretations this is common in multisited ethnography and vertical case analysis where joint discussions and analyses are used to identify tentative themes and questions about the emergent ideas practices discourses tools and institutional arrangements between and across our various sites over time altogether 340 hours of classroom observation were conducted they focused on presentations of place and on participation pupil influence and conflicts in the school as well as how places and their relations were presented and positioned in the curriculum and interactions the observations included field conversations but we have also employed formal interviews with pupils and staff at the schools which were also supplemented by observations in the neighbourhood and some document analyses by placing emphasis on learning from informants we have been particularly strong at providing details from interactions inside everyday life contexts and settings analysis and results in line with our aims and theoretical positioning whether and how teaching relates to place was inquired into as was young peoples views of inclusion fellowship and conflict and their positioning of the local school and community the analyses point to considerable differences between the researched schools and the results are organised under a series of thematised subheadings that try to express this these are differences when presenting the school local or nationalglobal relations the local context and its resources and urban estrangement as an educational interpellation and a policy dilemma differences when presenting the school local or nationalglobal relations one obvious characteristic of education is that the input in the classroom is not only meant to produce knowledge and skills that are specific only to the particular context they are meant to have value also to what is practiced outside of the classroom and for the future coastal school was at the other extreme it had few visible signs showing a recognition of value of the local neighbourhood in fact cultural and physical geographical imagined closeness to parts of the world other than to the local were stressed instead an example was when a politician during an interview and in public talk recurrently stressed that the swedish capital stockholm was only an hour away by air another was when an official in the municipality stated that you can live here and still be part of something bigger and there were also references to ideal identities as citizens of the world and to the advantages for young people of moving away from the area to widen their perspectives and opportunities references to the global context were used regularly to highlight the local communitys closeness to the wider world when you look at this you see that we are citizens of the world that goes for language as well almost all of us in the world speak english we are global citizens and we have a global language identity today is less connected to… where we were born we travel an incredible amount it is often cheaper to fly to the mediterranean than to stockholm the predominant representations from outside the school were from the world beyond the local neighbourhood but this does not mean representations of the local were totally absent they werent they were different whilst forest school lifted the value of the local positively in coastal school the reverse was apparent the view of the local community was typically one that was seen as needy and the local community was presented as benefitting from linkages to other places there were few examples of the value in the local context for global conditions and no forms of interdependence were described where the local community was also actively contributing these findings relating to forest and coastal school were also looked at in respect of the data that have been produced at the other sites what we found was that the differences in the spatially contextualised relations expressed about the local and the global seemed to relate to type of rural area the schools that positioned themselves in the local neighbourhood through material and social references that valorised local conditions values practices and conditions positively were typically from the more sparsely populated areas whilst schools with few or negative references were from small industrial communities the museum pedagogue held a lecture about local events during the second world war showed a film of local woman who was imprisoned in a nazi camp in norway and we walked through the museum to see the local artefacts from the war after this i ask some pupils about their… visit to the museum they said that it was interesting and that they knew of some of the individuals presented and that they got new information about them that they did not know before one pupil said that it was especially thrilling that a path she to take in the mountains had been used by refugees and had even died there a local garage owner visited the pupils to talk about human interactions and communication … to show that you must be able to communicate with tourists who arrive here and need to have their cars fixed you should actually be able to accept 30 000 people each summer and provide good service and be able to the unique assets of the local contexts that should be acknowledged not only by the locals but also more widely were characteristically made into central parts of various assignments at forest inland and mountain schools where it was also common to ask pupils to learn about and highlight what was valuable in the area in forest school forestry and associated small industries were highlighted in mountain school tourism culture and local history were highlighted and in inland school the region being unique biodiverse and rich in natural resources was stressed along with a notion of the value and challenges of an untamed nature and sustainability these interactions seemed to leave their mark on pupils and were often also reworked by them in terms of their life objectives which were more often oriented than in river or sea school toward a local future local value was seen also in other ways in home economics in mountain school for instance the teacher made a point of moose meat being a more sustainable meat choice than cow pig or chicken and this theme of the value of local game was repeated also by pupils in forest school a special sports event in school ended with a joint banquet with moose meat provided by the local hunters and when the pupils were to observe an animal dissection in biology class they were provided with a moose head not a more common pigs head the teacher continues that the next lesson they will start a new theme in biology we will dissect a moose head we will start with the eyes and then continue with the brain the teacher however makes a reservation because she is dependent on the luck of hunters i have some contacts and hopefully they be able to put a moose down for us the presence of themes of local nature in the sparsely populated areas accords with previous research rye for instance concludes from a review of empirical research that there is a coherent structure of how people conceive of the rural across europe he wrote that naturenatural seems the most prominent feature of rurality and that rural life is conceived as being more natural than life in the cities the pupils from the areas also took up this kind of positioning and identity including interestingly also new arrivals the local context and its resources the material value of nature in education there is a strong joint theme of nature and the good associated with it in the schools in the sparsely populated areas rural life is presented as close to nature and natural and both classroom observations and pupil interviews point to the strong appreciation of nature through tales and poems about access to forests mountains and rivers and the feeling of freedom associated with being in nature similarly to stenbacka there was a common language for expressing aspects of rural living such as peace quiet and freedom these are also features that figure in the representations of rural in other schools though less so and less spontaneously in the schools in the periurban industrial and deindustrialising areas like coastal river and sea school but nature in the sparsely populated areas is also presented as important for material survival hunting in particular is referred to in the researched schools as part of rural peoples livelihood and is frequently put forward by pupils as a prominent activity in local adult society that is also central to their own leisure time preferences the pupils discuss the benefits of the forest emphasising its peace and quietness the clean air and the fact that everyone has access to it they also emphasise… how important hunting is in sweden… one boy also talks about driving a snowmobile in the forest saying that the best places to go snowmobiling are in the mountains and that driving snowmobile is less controlled in sweden than in many other countries sports activities to practice in the forest are also mentioned they include orienteering horseriding and running spending time in the forest with the family and just having a cup of coffee or going fishing the teacher asks the pupils to elaborate on the meaning of hunting more specifically one boy answers it provides food another boy answers it limits the moose population nature is presented here as materially culturally and socially important but the economic and social values are also intertwined and the economic value of hunting is recurrently highlighted in relation to peoples often rather modest incomes the pupils have learnt about the different economic conditions in sparsely populated areas compared to the ones found in other spaces where commodity forms of labour value proliferate through industrial production also the pupils from the periurban and intermediate rural areas do not seem to consider the value of the rural in the same material terms as those from sparsely populated ares do they rather adopt the fetishized economic form of value of nature characteristic for metrocentric politics as identified in farrugia urban estrangement as an educational interpellation and a policy dilemma understandings of the value materiality demands and realities of life in sparsely populated areas and the dependency on rewards from and responsibilities toward nature that develop and are communicated in schools are sometimes put in contrast to urban life and its estrangement from nature an urban inability to understand rural life and to fathom the complexity and potential harshness of it is present in the comments from informants there is they suggest an inadequate urban relation to and understandings of nature in general and in the capital of stockholm in particular whose citizens and politicians in particular are regarded as not really having a serious conceptualisation of what nature really is urban estrangement is also coupled to an urban romanticising of nature for instance in forest school there was frequent mention of urban misconceptions of how to handle the growing wolf population in sweden those in power are said to argue for the preservation of wolves and decide accordingly without knowing about the reality of their presence a comfortable and urban middle class who have never seen a wolf or the damage it causes take a stance on what the acceptable size of the wolf population should be without understanding the dangers that rural people and domestic animals are subjected to the double economic value of hunting is also misrepresented urbanites only see this as sport or cruelty… but we dont have so many shops here… we hunt to get our food and what happens if the wolf takes it all within the common emphasis on rural closeness and dependence on nature in school content in the sparsely populated areas a rather striking difference could be noticed with the schools in the periurban and rural intermediary communities these schools made as mentioned earlier far fewer references to the local surroundings and their particular merits and impact but in addition there were also fewer explicit challenges to the urban norm of for instance restricting hunting and closing small schools in sparsely populated areas these come only from the sparsely populated rural areas as one teacher there said i am very tired of city life values being taken as a norm and schools being seen as better just because there are more pupils political decisions are clearly understood and communicated as having been steered by a metrocentric ideology not scientific facts local experience or a wellgrounded familiarity with rural life and rural spatial variations indeed according to åbergbengtsson scientific research seems to have only been heeded when it was in line with government ideas to globalise and urbanise the curriculum and its value base or to close rural schools rather than keep them open this seems to be detrimental to the educational opportunities available to and availed of by local youth in sparsely populated rural areas if there is an upper secondary school in their local town or at commuting distance it often has only a limited selection of programmes they also have fewer private supplier independent schools to choose from than do pupils in these other areas so even the new education politics of the education quasimarket seems to be failing rural areas which seems to affect students with shortage in economic social and cultural resourses more than other discussion what the present article makes very clear is that sparsely populated areas and rural intermediary and small industrial communities do not express the same kind of relationships through school content to the national and global context nor the same relations to their local environment neither rural areas the people in them or their curriculum contents are in any way homogenous there were some similarities though youth in both sparsely populated areas and in rural intermediary industrial and periurban areas related positively to the local context and their lives there in school however teaching in rural intermediary industrial and periurban areas also tended to buy into and reproduce aspects of the prodimant urban discourse that emphasises global interrelations as important and that represents rurality as a needy problematic context there was for instance often a clear encouragement from agents of the schools to pupils to leave the area for a better educational future and life opportunities and this was also picked up on by these young people to our knowledge this did not happen in the three schools in the sparsely populated areas where both teachers and pupils positioned themselves more distinctly in relation to their neighbourhood through curriculum content selections and presented their neighbourhoods in rather appreciative terms that highlight the presence of resources above the difficulties of living in a dwindling industrial economy this did not mean that these agents failed to see advantages with young people getting a good high school education that allowed them the opportunity to study further if they wish to and they also realized that young people might have to leave the local place at least temporarily to fulfill this ambition but nature itself was a point of value and this was represented in school in curriculum content and everyday interactions nature was associated with material value pleasure survival leisure freedom and a natural way of life it was however definitely not an idyll that was described in fact local voices almost always presented the notion of the idyll in relation to a critique of an urban estrangement from nature that had gained global precedence above the more realist local portrayal economic life was described as harder than in other areas and decisions by politicians from outside the region were described as being dislocated from local consciousness and problematic for local lifestyle and survival coming from a rural community was thus described in all six areas in relation to an urban discourse but there were two different urban discourses with distinctly different valorisations that were related to one by the schools in more sparsely populated areas and one by the schools from the three other areas the first discourse is a discourse about urban failure either in terms of urban inability to cope with nature or to understand it as with regard to its romanticising of nature or in terms of political metrocentricity and urban middleclass selfassumed sense of moral and intellectual superiority åbergbengtsson also pointed to this problem politics are being made based on distanced and inaccurate misrepresentations of rural needs and conditions through a middle class metrocentrity that works against the interests of communities not for them in the sparsely populated rural areas individuals perform and describe a way of life a culture where nature is a link between people and their surroundings that is fundamental to the physical and cultural survival of the place and the people in it these things are given a place in school content too and can be seen in interactions in local school interiors and in the curriculum individual pupils school practices and content differ within the sparsely populated areas with respect to type of local conditions and local activities in this respect there is a generally closer relationship expressed to local conditions and a reliance on them is described in school content in the more populated perurban rural areas there is a different interdependence expressed in relation to economic production more extended levels of differentiation are expressed based explicitly a more complex local division of labour and the fusion of markets a value is described too in relation to the growth of cities and interdependency in social and global economic bonds and these things are also specifically reproduced in the local curriculum some key themes can be identified as intertwined within the disclosures of the article in these repsects they include a global urban middle class hegemony and a policy inaccuracy for sparsely populated rural areas and their people that is related to it as corbett describes things the global middle class urban hegemony also creates and then uses a negative imagery and preassociations of place and space against the interests of a concept of an active rurality as a value in its own right in and in relation to schooling processes there idealisations are produced on the one hand and discourses of cultural deficit concerning the people from rural places on the other both of which lead to a politics that can add weight to a further economic and social hollowing out of these regions as described by åbergbengtsson this kind of hollowing out includes the merger and closure of schools and increases in fiscal and temporal costs for rural youth to gain an academic education with a high exchange rate value thus official politics not only fail to make positive identifications of rural conditions they actually significantly misrepresent people the characteristics of the places they live in and their interests skill sets and commitments productive capital in rural areas in sweden has historically been associated with agriculture forestry mining and timber and woodpulp manufacturing and what we have identified is that whilst these productive forces remain important in any given rural area spatial vitality seems to be identified in terms of the local production economy and its position within a global network of capitalistic relations and examples of the local production economy will often be found in school content however when there is an absence of agricultural mining or production industry other foundations of spatial value need to be found to maintain an understanding of local places as being vital social and cultural spaces and we have identified different features in these respects the identified features include tourism recreation and hunting supplementary economic activities and they challenge typical ideas of rurality as concerned with isolation poverty marginalization depopulation conservatism racism exclusion and and in particular passivity moreover we also identify different educational content inclusions corresponding to them and as åbergbengtsson we also begin to suspect that the negative valuations of rurality are semifictional hegemonic products of modernity and postmodernity that are ideologically imposed on rural spaces they represent in this sense another aspect of industrial and postinstrustrial political metrocentricity that seldom construct rurality as constituting dynamic possibilities that have their own values independent of urban conditions what we indicate is that local people can both transcend this hegemony and construct a positive concept of the value of rural spaces and carve out a meaningful place for education in relation to these local value sets the ideologies of the big school as better and the urban middleclass as cleverer are part of this problem but also other complex difficulties that face the rural reach have emerged among the indications and implications from our research the first of these involves the continual need to consider and counter current historically structurally formed forms of class cultural superiority that can work as a hegemonic force to help sustain the social reproduction of ideologies of difference with material consequences these cultural practices are ingrained in our political institutional and legal structures and are almost quite literally taken for granted they are embodied in our schools through the content structure and workings of the official curriculum and their presence and current domination of official educational codes make any claims toward educational justice and fairness in our educational system questionable these things can be sensed very easily from the present study ideology and social representationsdiscourses have been identified that favour urban political models and curriculum modalities that reproduce them but also important is the ways they can be and are countered in living educational spaces and processes through conscious and unconscious acts of resistance the message from this for education politics is that the dominance in education policy of metrocentric values and middle class educational codes and ideologies is a problem for sparsely populated areas and the pupils there but that adults and children with strong links to rural communities are still able to define value in terms of local conditions through loyalties that exist in relation to local culture rather than national authority systems these loyalties can be seized upon and used ina more progressive curriculum that is better geared to and driven by local values and local knowledge official representations often stubbornly distort the real conditions and needs of rural communities these conditions today include the material hollowing out of regions capital flight movement of commodified labour and negative representations of places and their people they are apparent in many rural areas and despite extended economic demands are imposed on rural parents through education centralization effects parents in rural areas particularly remote ones more often belong to low income levels and they are now having to pay for their children to attend a school further away in terms of both travel time and the social distance of educational content to home conditions and values with this inducing a double problem of education justice rural childrens future education plans have been identified to be in line with the economic realities of their neighbourhoods and their families and although parents are reluctant to talk about it the fact is that the poorest among them simply may not be able to afford to bear any further increases in their fiscal responsibilities for the education of their children what price then the swedish model of an equitable standard of freely available public comprehensive education that is easily accessible for all when parents have to foot the bill of an increasingly alienateding education for their children conclusions the rural in relation to rural education be this in terms of politics or experience is rural precisely in terms of its relationship to three dynamic variables according to balfour et al and in line with corbett farrugia and massey we have described them as forces agencies and resources that are lived and intervene in education processes as social factors that account for both behavioural variations and differences in relation to the selection and treatment of local content in educational places they are described in relation to the conditions of economic and cultural production the convictions of value that agents generate and the push vs pull forces they may exact and are visible in terms of how three of the schools from three sparsely populated areas showed recurrent references to the local communities and their traditions and values in school activities and talk these schools explicitly positioned themselves in the local neighbourhood through their discourse with strong discursive strands connected to the concept of local value this isnt seen to be the case in areas that were once more emphatically tied to manufacturing industries in these places the hegemony of metrocentricity is more often reinforced than challenged and a sense of an experience of a loss of local value prevails over the presence of senses of an experience of alternative value forms to those of the global economy this is also visible in terms of how the local and the global are included in school content and everyday school discourses and we suspect that it can and does have effects on school motivation and behaviour and our call in educational terms is in this sense one for a ruralplaceconscious education politics which links to the actual conditions of rural lives rather than relationships to the urban domain and the current hegemony of global economic productivity we believe this could be of value in relation to countering what corbett and balfour et al have described as a diseased political discourse in relation to the values and charateristics of rural life

the present article has used ethnography to make participant observations in six local neighbourhood schools in rural parts of sweden together with interviews and the collection of local documents it shows three things in particular that also relate to how rural education is described in other european educational research these are firstly how rural communities and their schools are very different to eachother and are differently affected by global processes to which they are nevertheless distinctly related and differently positioned and affected by national education policies secondly what the visible effects of this seem to be on schools education and educational experiences motivations and behaviour in local communities thirdly what the possible policy implications of this can be for a more generative theory and politics of rural schooling today

incidents of severe targeted school violence and terrorist attacks are usually considered as distinct social phenomena although no clear and unequivocal definitions have been formulated for either severe targeted school violence is generally understood as targeted attacks committed by school students where the school is deliberately selected as the location and lethal weapons are used with the intention to kill while these incidents are driven by personal motives associated with the school context and usually understood as personal revenge for experiences of humiliation terrorist attacks are normally defined as acts of violence directed against a political or societal order terrorism is always embedded within a communication strategy designed to have farreaching psychological effects beyond the immediate victim namely by generating public fear within a wider audience the addressees might be a rival ethnic or religious group an entire country a national government a political party or public opinion in general hence terrorism is defined as asymmetrical deployment of threats and violence against enemies using means that fall outside the forms of political struggle routinely operating within some current regime according to the current state of research differences between severe targeted school violence and terrorist attacks are found in the locations targeted and above all in the motives tending to be personal in the case of rampage school attackers politicalideological or religious in the case of extremist or terrorist violence additionally the two phenomena are investigated within different research traditions exhibiting few points of contact to date however several incidents that have occurred over the past ten years in europe appear to combine elements of both severe targeted school violence and terrorism one example is the case of pekka a who killed eight people and himself in a school in jokela finland on november 7 2007 a media portfolio prepared beforehand included the following statement attack type mass murder political terrorism before the attack pekka a had pursued an intense interest in rightwing extremist violence another relevant case is the osloutøya attack in 2011 which was characterized by elements of an extremist motivated attack in their study of the writings of the attacker anders b sandberg oksanen berntzen and kiilakoski demonstrate that the attacker was not only influenced by the rhetoric of rightwing islamophobic groups but also by the cultural script of school shootings in advance of the attack b withdrew almost completely and restricted his social life to the online context his preparations for the attacks were comprehensive drafting numerous statements justifying his actions and presenting himself as the defender of european culture the modus operandi of his attack at the workers youth league summer camp on the island of utøya also showed strong parallels to school shooting cases similarly in the 2016 attack on the olympia shopping mall in munich germany elements typically discussed in connection with severe targeted school violence can be identified as well as features of a rightwing extremist attack the classification of this attack remains politically contested in germany while politicians and law enforcement agencies categorize the attack as a rampage shooting researchers tend to classify it as a case of lone wolf terrorism in the past ten years there have also been cases with an islamist background combining elements of rampage shootings and terrorist attacks examples of such incidents in germany would include the attacks at frankfurt airport in 2011 würzburg and ansbach in 2016 the occurrence of cases including elements from both phenomena is not surprising considering the observable changes in terrorist strategies over the past twenty years for example in the field of rightwing extremism american racists tom metzger and alex curtis propagated leaderless resistance as a white resistance strategy in the late 1990s similarly tendencies of individualization of terrorist strategies are also observable in the field of jihadist terrorism since alqaeda called on followers to engage in leaderless or individual jihad a number of terrorist attacks in the style of a rampage killing by n böckler et al comparison of school attackers and jihadi attackers individual perpetrators or small groups later followed such recommendations on the other side cases like the jokela school shooting demonstrate that at least sometimes a young person committing a targeted attack in a school intended to send a political message and had an affinity to terrorism malkki focusing on the presence of political elements in school shootings distinguishes three types cases with explicit political communication by the perpetrator cases in which the perpetrator made references to earlier attackers and isolated cases in which the perpetrators made no references at all in terms of the motivational structure type 1 and type 2 appear most comparable with acts of terrorism as in the field of terrorism perpetrators of targeted school violence have also influenced a wider audience larkin demonstrates how the school shooting at columbine high on april 20 1999 in particular created a cultural script for later school attacks columbine high stood out from other incidents of targeted violence in schools in the sense that both perpetrators regarded it as a subversive act of political violence in the name of all who experience social repression at school this growing phenomenon of combination of elements of terrorist attack and targeted school attack has initiated a discussion concerning the similarities with a growing number of comparative studies lankford and hakim compared american school shooters with palestinian suicide bombers and found strong parallels in terms of psychological constitution and motivation the perpetrators in their study share many characteristics in common such as a highly troubled childhood social deprivation and low selfesteem in both cases personal crises represent the starting point for the turn to violence with the underlying motives of avenging injustice and acquiring fame and repute the study builds on the observation that both groups are homicidalsuicidal lankford and hakim criticize the widespread dichotomy that regards school shooters as psychologically unstable suicide bombers as extremist but rational according to their findings the differences between the two groups are cultural rather than personal in nature similar results are found by mccauley moskalenko and van son in their comparative analysis of school shooters and politically motivated attackers in both cases the perpetrators planned their actions in advance usually acted alone and drew their motivation more from emotionalsocial than material or instrumental needs biographies in both groups are characterized by depression despair and suicidal tendencies significant differences exist only in relation to age and marital status politically motivated attackers are considerably older and more likely to be married capellan compared ideological and nonideological active shooter events in the united states between 1970 und 2014 finding similarities in the demographic and personal profiles but significant behavioral differences between nonideological and ideological motivated perpetrators capellans empirical findings indicate that ideological shooters act more methodically and show higher levels of sophisticated planning have experienced some kind of military training and use a greater number of firearms but for the most part the shooters in both groups were white males in their thirties with dysfunctional adult lives single or divorced with lower levels of education and a history of mental illness capellan argues that the reason for these similarities is that whether ideological or nonideologicalshooters were driven by both personal frustrations and aversion towards society interpreting the two phenomena as subgroups of a homicide type that he calls lone actor grievance fueledviolence liem van buuren de roy van zuijdewijn schönberger and bakker compared characteristics of lone actor terrorists in europe in the period 20002016 with ordinary homicide offenders the demographics and perpetrator profiles led this group of authors to nearly the same conclusions as capellan with the difference that the ideologically motivated perpetrators exhibited higher levels of education than the ordinary homicide offenders it is also noteworthy that ideological lone actors were not usually socially isolated and operated in dyads and triads more often than ordinary homicide offenders who usually acted alone böckler roth stetten and zick argued that besides being risky for development violent behavior is also temporarily highly functional and productive for the psychosocial wellbeing of the perpetrator in order to gain a deeper understanding of the developmental pathways towards school shootings and terrorist attacks and to comprehend individual motivations we have to move beyond the mere accumulation of empirical findings what is needed is a theoretical point of reference that provides some guidance for interpretation and facilitates the important progression from description to explanation böckler et al point out thatalong with the push factors generating pressure to n böckler et al comparison of school attackers and jihadi attackers cope with intrapersonal tensions it is important to look at the pull factors and relational dynamics that make a specific action attractive from a social psychological point of view we must therefore also consider contexts in which narratives and scripts supporting violence are disseminated and the question of how these contexts are adopted by the perpetrators this perspective is also reflected in several works focusing on the question of how lonely a lone wolf really is borum et al note that cases in which the perpetrator plans an attack completely without outside influence encouragement or inspiration are very rare in this context van buuren points out that also most lone actor terrorists understand themselves as part of a broader community while virtual spaces especially social media often function as a surrogate for offline social networks demonstrative targeted violence a sensitive concept böckler and colleagues recently introduced the concept of demonstrative targeted violence to describe the overlap between severe targeted school attacks and terrorist violence while demonstrative targeted violence generally occurs in a public space the victims are selected for their symbolic significance to the perpetrator according to leuschner this kind of violence involves a demonstration of the vulnerability and destructibility of what the perpetrator regards as a powerful group or institution there is always a communicative meaning that transcends the attack itself böckler and colleagues describe such acts of demonstrative targeted violence as an expression of personality in which the perpetrators seek to gain social recognition by presenting their personal andor social identity on a public stage this selfstaging in turn indicates a social identification with scripts of violence groups andor ideologies on the other hand the act of demonstrative violence is also a form of directed communication seeking to draw attention to injustice to spread fear and panic or to mobilize others to fight for the same cause however it also indicates the perpetrators need to justify their actions to themselves and others against the background of these fundamental similarities in the modus operandi of severe targeted school attacks and terrorist attacks böckler and colleagues present a theoretically grounded pathway model for the development of demonstrative targeted violence while perpetrators of targeted violence in schools and terrorists generally seem to exhibit functional cognitive processing of reality personal grievances and crises mark the start of a developmental process leading to an act of demonstrative violence in this context the planned style of targeted school attacks and terrorist attacks also suggests similarities in the preparation processes the planning phase and the acquisition of competence at violence the existing research on both school shootings and terrorism indicates that the perpetrators redefinition of self from victim to selfperceived avenger is associated with selfempowerment for violent action the perpetrator increasingly moves into a phase of clandestine planning characterized by a state of tension between secret private rituals and public intimation many investigators have been able to reconstruct different trigger events after which the perpetrator might view the act of violence as necessary justified inevitable and meaningful the presented heuristic model forms the backbone for our theoretical coding procedure and the constant case comparison our aim is not to test the above mentioned model in a hypotheticodeductive manner but to treat it as a sensitive concept from which we derive an empirically grounded model of perpetrators developmental pathways towards demonstrative violence to use blumers words whereas definitive concepts provide prescriptions of what to see sensitizing concepts merely suggest directions along which to look they rest on a general sense of what is relevant we therefore constantly consolidate modify and differentiate categories using case comparison and combine these findings with the hypotheses arising from the theoretical knowledge in the field method sample our study is based on data collected within the national research project target case analyses of severe targeted violence which set out to analyze all incidents of severe targeted violence in germany between 1999 and 2013 for case recruitment we distinguished two groups severe targeted school violence comprising attempted or completed attacks in schools 1 committed by a current or former student of the school 2 planned and executed with potentially lethal weapons and the intention to kill one or more persons associated with the school 3 where the attack at least commenced and 4 when the perpetrator had not yet reached the age of twentyfive and targeted attacks with ideological or religious background comprising attempted or completed attacks directed against the political order in which perpetrators referred to an ideological or religious worldview for case identification we conducted systematic recruitment by keyword search with german search terms terroranschlag amok and school shooting in media reports using the electronic media archives genios and lexisnexis which cover about 340 germanlanguage newspapers and journals we identified fortysix targeted attacks in schools and fortyseven targeted attacks with ideological or religious background in a second step identified cases were categorized by two separate researchers using the identified media materials and our aforementioned definitions for deeper investigation we selected thirtyfive cases of targeted attack in schools and twentyone cases of targeted attack with ideological or religious background in all selected cases we requested access to the prosecution files after initial analysis of the documents we excluded all cases which did not fulfill our criteria after this third step we were left with a sample of nineteen targeted attacks in schools and twentyone targeted attacks with ideological background for the case analyses and comparisons in the present contribution we used a subsample of symbolic school attacks and homicidal attacks with jihadi terrorist background cases of severe targeted school attack were classified as attempted or completed n böckler et al comparison of school attackers and jihadi attackers symbolic school attack if victims were chosen for their symbolic meaning as members of the school rather than because of personal conflict homicidal attacks with jihadi terrorist background were defined as attempted or completed attacks in which the perpetrator referred to a jihadi movement or organization we included only perpetrator who had been socialized in germany before they decided to plan an attack and excluded cases where the perpetrator entered germany specifically to commit an act of terrorist violence ultimately seven cases of symbolic school attack by single perpetrators were selected and three cases of homicidal attack with jihadi terrorist background all incidents investigated occurred in germany the school attackers ages ranged from 13 to 23 years two offenders were female and four committed suicide after the offense the terrorists ages ranged from 20 to 28 years all were male none committed suicide in connection with the incident materials and data analysis data about attacks and perpetrators includes prosecution files and additional material such as interviews with imprisoned perpetrators all files included witness statements and police reports for ten perpetrators the files include court judgements and forensic psychological assessments and for eleven perpetrators personal writings and testimonies we first ordered all relevant information about the perpetrators chronologically from birth to offense and prepared biographical case descriptions in order to analyze the developmental trajectories of perpetrators in the next step data was coded following the theoretical coding method two researchers coded the material independently and discussed diverging interpretations until agreement was reached in this way biographical trajectories relevant life events and turning points were reconstructed for each case and developmental pathway types were described for the present paper important concepts and categories gained from inductive analysis were used for an indepth case comparison of the subsample of cases from both case groups results according to our theoretical concept we will describe similarities and differences between the two groups of perpetrators in terms of their developmental pathways in the runup to the violent attacks dispositions and functional processing of reality in our analysis there is little evidence for the hypothesis that pathways towards targeted attacks in schools or jihadi terroristic attacks are determined by mental disorders only in one case of school attack there is evidence for a lack or loss of ability to exercise control in the attack situation caused by schizophrenia in the sample of terrorist attackers we found no evidence at all of a causal effect of mental disorders nevertheless there is evidence in all cases that mental disorders and specific mental dispositions may have framed the perpetrators perception of reality and social relationships mental dispositions are understood here as the result of individuals personality and early socialization experiences our case analyses revealed two typical dispositions from early childhood on aggressive and impulsive tendencies on the one hand and introverted characters on the other hand within the first type subjects showed aggressive and impulsive tendencies and low selfcontrol as a result of early problems in the family setting these individuals also showed early behavioral problems in the peer context and school often classified as antisocial behavior attention deficit and hyperkinetic disorder while none of the investigated school attackers fell into this category the sample of jihadi terrorist attackers included four cases in which the subject for example attracted attention with criminal and dissocial behavior in the run up to their radicalization the second class of perpetrators presents as sensitive introverted inwardly focused and nonassertive in advance of the attack some of them had health issues and physical abnormalities poor social skills and poor school performance one school attacker suffered from klinefelters syndrome which can cause symptoms like small testes tall stature gynecomastia and failure of normal sperm production he was teased continuously by his peers about these physical symptoms which resulted in low selfesteem and depressive withdrawal within their further developmental pathways some of the later perpetrators evolved a compensatory narcissistic or schizoid personality structure among the sample of school attackers all seven cases show some indications of personality anomalies but there were no proper psychiatric or psychological diagnoses in the sample of terrorist attackers two individuals showed clear internalized coping behaviors along with narcissistic personality accentuations in advance of the attack the cases 2 ter and 7 ter repeatedly experienced depressive and partly suicidal tendencies in social contexts they presented as reserved and showed very little personal initiative while withdrawing from society and everyday social life they developed compensatory fantasies of being omnipotent avengers and taking part in violent jihad grievances for all school attackers and jihadi terrorists in the sample we can identify grievances in socialization contexts which in some cases culminated in personal crises subjectively perceived as highly significant in most cases these experiences were associated with major life changes that triggered severe feelings of powerlessness and disorientation the family context problematic parenting styles and lack of social support there is considerable variation in the formal composition of the families in which the perpetrators grew up ranging from intact nuclear families singleparent families to foster families in all of these socialization contexts problematic social dynamics were identifiable in the sample of school attackers most parents experienced their child as physically weak and clumsy in interpersonal relationships but in none of these cases did parents actively support the process of identity exploration instead they pressured their children toward their own preferred outcomes such as academic performance sporting success or masculinity thus personal crisis often resulted from discrepancies between parental expectations and selfawareness one typical example is a case where the parents always compared the young man with his successful older brother they pressured him to attend a selective academic secondary school his failure there was the initial trigger event for the later shooting in the cases of jihadi terrorists the subjects felt somehow insecure and disoriented in their families for both groups the dominant factor seems to be a familial atmosphere characterized by emotional indifference and a lack of parental involvement the parents of the later perpetrators were mainly concerned with their own worries and activities and showed little presence in the life of their children in some cases family life was overshadowed by burdensome social dynamics derived from parental divorce and associated perceived crises of loyalties illness and death of significant others and longterm separation were also identifiable factors 1 ter and 2 ter for example felt totally separated from their family and their familiar culture before they jointly decided to plant bombs in two german passenger trains 1 ter and 2 ter came to germany to study two years before the incident soon they felt overwhelmed by multiple stressors with spatial separation from their families creating pressure to perform and exposing them to new unknown cultural codes while 1 ter quickly tried to compensate his feelings of disorientation by escapism in salafist ideology 2 ter spent most of his time aimlessly surfing the internet before 1 ter eventually recruited him for his attack plans our case analyses reveal that perpetrators with migration background often perceived themselves as experiencing a challenging balancing act between two cultures they perceived western culture and behavioral codes they were confronted with in school and at work as a world apart from their family life at home their parents were not well integrated and due to lack of language skills communication between parents and schools was often difficult within their western living contexts the young people deeply missed functioning role models as they found themselves forced to face the challenges of everyday life on their own a futile search for orientation became a central element in the developmental pathways of 4 ter 5 ter and 7 ter 5 ter for example stated during the police investigation he started to perceive his father as a weak man after he moved to germany he was obviously unable to cope with life in german society 5 ter soon was yearning for other role models whom he eventually n böckler et al comparison of school attackers and jihadi attackers found in the authoritarian but charismatic preachers of a local salafist group 7 ter also described his fathers severe illness as a turning point in his life after a heart attack his father was unable to work and became increasingly dissatisfied with his situation during this time 7 ter started to regard himself as a goodfornothing he was unable to contribute any income to the family and at the same time failing at school when he eventually had to repeat a grade he perceived himself as a complete disappointment for his parents due to a great sense of shame he failed to tell them when he had to repeat a second year and eventually left school without any qualifications the peercontext disrespect and bullying among peers the peer context can be understood as the most important social space in the phase of identity formation for the school attacker sample it is obvious that this social space is experienced as problematic and exclusionary from the perspective of the later perpetrator nearly all of the later perpetrators felt harassed persecuted threatened or hurt by the majority of their peers early experiences of exclusion by peers fuel a process of social withdrawal and create a strong need for public recognition several cases illustrate how early experiences of peer exclusion created a continuous point of reference for violent thoughts one perpetrator wrote in his diary five months before the attack that he had never forgotten the feelings of shame and helplessness when he was beaten on a school excursion six years previously another perpetrator reported on a psychological counselling website that his experience of public humiliation by his peers was the turning point that generated a strong desire for revenge while all investigated school attacker cases feature at least subjective peer exclusion such experiences of humiliation were not identified in the sample of terrorist attackers the school and workplace context school and work problems for both groups school attackers and jihadi terrorists formal educational careers were characterized by inadequate performance in school and university dropout and precarious employment in these contexts we identified two central patterns in the first pattern the perpetrators initially showed no abnormalities in their conduct at school or work a drop in performance or withdrawal from peers and colleagues marked significant changes in their behavior in two cases in the jihadi terrorist sample classmates reported that the later perpetrators attracted the attention of teachers and peers when they suddenly started to glorify terrorist organizations and violence quitting school and work were active decisions by the later perpetrators triggered by personal crises a successive orientation towards ideological contexts and the prioritization of religious practices for those who quit school early this pathway continued with precarious employment and uncertain prospects in the second pattern later perpetrators had difficulties coping with school from the start and had to repeat several grades some school attackers and some of the jihadi attackers also experienced heavy parental pressure to perform in both groups we observed conflicts between the later perpetrators and teachers as well as classmates in one case of severe targeted school violence the perpetrator attacked a teacher who he felt had humiliated him seven years previously another perpetrator who was expelled from school for falsifying a medical certificate only targeted teachers in his shooting attack while later school attackers showed a cognitive fixation on previous humiliations by peers and teachers we were not able to identify the same for the terrorist attackers whose orientation on ideological contexts played a compensatory structuring and senseattributing role in the course of their radicalization process ideologies faithbased practices and group dynamics increasingly replaced other everyday activities positive social feedback which the later perpetrators perceived as important for the stabilization of their identity increasingly came from ideological contexts the personal grievances the perpetrators of both groups suffered in the course of their biographies present as very diverse the common factor is perceived fundamental incongruences between realself and idealself resulting in severe chronic strains and extreme strategies to cope with them these grievances produced an openness for ideological contexts and alternative worldviews as constraining ties bonding them to socialization agents outside of radical contexts were absent n böckler et al comparison of school attackers and jihadi attackers identification with ideological and cultural scripts and redefinition of selfconcepts exposure to and confrontation with general mythodologies of violence eventually set the course towards the violent acts sutterlüty describes such mythodologies as scripts in which the use of violence is linked to categories like power strength and manhood for example as presented in many films computer games and other cultural products we identified a strong fascination for such narratives in almost all the investigated school attacks this was for example reflected in intensive reception of action and horror movies computer games and in strong identification with warriors fighters and in some cases even mass murderers sutterlüty points out that perpetrators who refer to such mythodologies of violence often associate their planned deeds with great expectationsnamely to gain social recognition by exerting power over others at the same time these expectations push them further and further towards the realization of their phantasies this is true for both groups in our sample school attackers and jihadi terrorists with the difference that social relationships and group dynamics played a more central role in the sample of jihadi terrorist attackers while friendships and social networks preceded the perpetrators adoption of jihadi ideology and also their readiness to use violence later school attackers were directly and more intrinsically motivated to use violence as revenge against those who they felt had humiliated them if at all not offline relationships but online social networks and identification with former perpetrators conditioned their adoption of cultural school shooting scripts however we were able to identify forms of ideology appropriation for school attackers as well as for jihadi terrorists jihadist attacks radicalization online in friendship networks and in isolated dyads for the jihadi group attackers as well as for the single lone jihadi terrorist in the sample growing commitment to ideology and the social collective behind it drove the radicalization processes further and further towards violence the later perpetrators active engagement with the ideology was initially rooted in its attractiveness as a rigid and guiding world view and their desire to belong to a social network subjectively perceived as morally superior the jihadi terrorists in our sample increasingly interpreted their own life in the light of ideological meaning schemes for example 7 ters turn towards islam evolved in a period of inner disorientation and depressive mood like 3 ter 4 ter 5 ter and 6 ter 7 ter expected to gain inner peace structure and discipline by devoting himself to religious beliefs and practices as he had nearly no relationships with other practicing muslims 7 ter tried to learn about islam in a rather autodidactic manner especially via online social networks he read the quran in german but soon recognized he had reached the limits of his ability to comprehend this changed when he came across salafist preachers on youtube who gave him an easy understanding of the religion by reducing its complexity to a binary black and white logic the algorithms of facebook and youtube provided him with more and more neosalafist and jihadist content as well as links to forums like the alqaeda global islamic media front over time 7 ter became increasingly confident in his ideological knowledge and at the end of each day he was satisfied if he had managed to comply with the strict religious rules and practices this represented a possibility to prove himself and by doing so to regain a sense of selfrespect after his attack investigators found more than one thousand jihadist files on 7 ters computer a majority of them propagating the duty of every muslim to fight against western crusaders and unbelievers the role of social networks while most of 7 ters radicalization took place in the context of online social networks preexisting friendship and kinship ties brought 3 ter 4 ter 5 ter and 6 ter into contact with radical and ideological milieus for example about five years before his attack 3 ter was led to a radical form of islam by an acquaintance with whom he had played basketball in 3 ters words he had realized that all the pressing questions about life which had haunted him since he was thirteen years old found an answer in islam during a period when he felt uprooted he decided to convert from this point on he spent more and more time in groups that propagated a radical interpretation of islam and sympathized with violent jihad 6 ter in contrast was socialized in a largely turkish circle of friends the parents of one of his best friends held extremist beliefs they repeatedly invited 6 ter for lunch and dinner eventually he converted when he was sixteen years old he stated that conversion to islam was a rational decision for n böckler et al comparison of school attackers and jihadi attackers him because islam provided him with more answers than any other religion it was a decision he made during a time when he was experiencing problems in the family and had several severe conflicts with teachers 3 ter and 6 ter both quickly found strong connections in the salafist community where they were entrusted with tasks and functions 6 ter became an editor of an islamist publication that glorified violent jihad and the mujahedeens fight against the west in our sample we also identified radicalization processes in close dyadic friendships as in the cases of 1 ter and 2 ter malthaner and lindekilde demonstrate the centrality of the building of social bonds that promote intense loyalty emotional support and intensive interactions for the radicalization of individuals within small groups and dyads these new bonds promote increasing isolation from the previous social environment and draw radicalizing individuals closer to radical interpretations school attackers and their perceived connectedness identification with other attackers while in the sample of jihadi attackers deep identification with other attackers developed in later stages of radicalization identification with former attackers and their selfpresentation was an initial starting point for most of the school attackers pathways towards violence in drawing on the school shooting script they changed their interpretative patterns in relation to self and world in a manner similar to the terrorist adopting jihadi ideology the more they were able to recognize their own experiences in the biographies and selfpresentation of former school attackers the more they considered an attack of their own as an option a potential solution to their individual problems our case studies include personal documents diary entries and downloaded materials indicating strong identification with former school attackers in one case a female perpetrator wrote the following in a friendship book at the age of thirteen about me i hate my life my major role models dylan klebold eric harris also known as the rampage shooters of littleton i dont go jogging im running amok i dont write poems i write my suicide note i dont like shopping for clothes i like to buy weapons another perpetrator wrote in his diary eric harris probably the most reasonable boy a high school can offer eric harris is god there is no doubt it is terrifying how alike eric is to me sometimes it feels like i am living his life again as if everything is repeating itself i am not a copy of reb vodka steini gill kinkel weise or anybody else i am the advancement of reb i learnt from his mistakes the bombs i learnt from his whole life the same perpetrator often visited the website and wrote in his diary that he had read there about the tcmsd an online fan base of school shooting fans the diary entry ends with the words outsiders of germany unite in several cases perpetrators understood themselves as part of an online community of individual outsiders the school attackers in our german sample who referred to former attacks and perpetrators also started to produce selfpresentations like their role models did in the runup to their own acts of violence these productions reflected their desire to create a new definition of self namely a transformation from victim to morally superior avenger from a social relational point of view the radicalization processes of school attackers can best be compared to the radicalization process of the single jihadi lone operator in our sample who radicalized online in the context of a virtual community redefinition of self in all cases we found one common feature of the radicalization process which we describe as a redefinition of selfconcept during the process of growing identification with an ideological or a violenceglorifying worldview radicalizing individuals are increasingly motivated to interpret and consolidate their selfconcepts in terms of these mythodologies the process comprises not only growing interest in an alternative radical worldview but also its habitualization we identified different forms of such processes sometimes the redefinition of self is overtly presented and verbalized in other cases the process proceeded silently and found expression only in behavioral changes by comparing these redefinition processes we were able to identify typical patterns which we describe in the following n böckler et al comparison of school attackers and jihadi attackers from disrespect and failure to recognition and significance the first redefinition pattern is focused on public recognition and individual significance and is found in all cases of school attackers two slightly different versions can be described firstly in a resistance pattern subjects suffered from experiences of disrespect and a loss of recognition in social relationships in the family or more often in the peer context they regarded themselves as at the mercy of others and felt discriminated and isolated in this pattern we find a strong desire for revenge for previous slights and social exclusion identification with radical opinions and ideology and with associated role models serves to acquire at least some kind of negative recognition and notoriety here we often found a specific date on which the later perpetrator presented their new selfconcept in public in order to capture the interest and attention of the exclusionary reference group in the second version of this redefinition pattern feelings of inferiority and a strong discrepancy between ideal self and real capacities are the starting points typical features include strong parental pressure regarding academic performance or masculinity and assimilation in the ideal self of the later perpetrator when the subjects realized that they were not able to fulfil the desires generated by their ideal self they became depressed and suffered selfdoubt and fear of failure from the sample of jihadi attackers the case of 7 ter is prototypical here as his fathers illness his failure in school and his familys financial difficulties led to extreme feelings of guilt towards his parents his desire to stabilize his selfworth to feel useful and needed increased more and more his orientation towards islamist content via the internet satisfied his need for clarity and guided him towards new social contexts in the course of his radicalization his focus shifted more and more from his own personal grievances to the grievances of all muslims while he was helpless in the face of his own problems ideological contexts provided him with possibilities to perform a great service in the fight for the global muslim community and thereby to identify himself with the mighty mujahedeen and its martyrs that pattern is also typical for school attackers who seek to communicate a message through a symbolic attack however for school attackers the interest in radical ideology and violencerelated scripts is not contentrelated but emotional a search for significance and greatness using radical violent means to prove their prowess and demonstrate their abilities both version of this redefinition pattern include a shift from selfperception as failure to selfperception as a significant and powerful individual and a desire for public recognition from nobody to charismatic leader some of the later perpetrators were deeply concerned about their social impact from early on they showed a strong desire to prove themselves within social networks exerting control and influence were central social motives they were eager to become opinion leaders within most of their social contexts their demonstrative identification with extremist beliefs became an important means of selfexpression these perpetrators served as an identification figure for other members of the terrorist group as they were perceived as determined selfconfident and extremely dominant in social contexts they therefore had an active influence on the radicalization processes of others as they set the trend for the violent behavior of the group at the same time positive social feedback within and from the radical contexts consolidated the radicalization processes of these individuals for them radical social spaces advanced to a main source of their emotional and social recognition from loneliness to social embeddedness the commitment of these perpetrators to the extremist contexts arose mainly from social relationships and less from a deep faith in ideology the central motive for engaging in violent acts was the desire to experience a stronger sense of social belonging thus ideology itself played a subordinate role for this socially dependent type of perpetrator perpetrators in this group were searching for other individuals to provide them with orientation and behavioral security therefore they were highly sensitive to the influence of others the planning of an attack also stemmed more from a sense of increasing commitment towards other people or social networks than from intrinsic ideological beliefs each perpetrator in this category had a close relationship to a person who he regarded as an authority figure as these individuals cut themselves off from networks outside the radical contexts they became more and more dependent on their mentors the radicalization process consolidated as a result of their social experiences within the radical contexts indoctrination and an increasing feeling of commitment towards their confidants clandestine planning for both jihadi attackers and school attackers a phase of clandestine planning has been identified in the developmental pathway in the runup to the attack this phase is characterized by selfempowerment for violent action increasing thoughts and fantasies about an attack and clandestine planning as well as preparation activities the duration of this phase ranges from two to six months our analyses indicate that clandestine planning is a central factor in the genesis of symbolic attacks radicalization in social isolation or within small radical groups is characterized by secrecy which produces a restriction of everyday interaction and communication social relationships beyond the radical social space become weaker and less important this means that delinquent thoughts and actions of the isolated person or radical group have to remain hidden and protected from discovery by others especially law enforcement the fact of secrecy produces decisive aspects affecting escalation because the interaction processes with the real or imaginary peer group are hidden and clandestine they are subject to a disinhibition mechanism that causes steadily growing polarization towards groups and individuals perceived as hostile and confirmation of the perpetrators own convictions this disinhibition mechanism has been described both for facetoface interactions in clandestine groups and in the context of online disinhibition for interactions on the internet the permanent danger that high risk activities may be discovered requires clandestine social structures in the form of hierarchies and rituals and associated sanctioning it leads to the emergence of protective mechanisms in clandestine groups hierarchies serve to exercise strong control and pressure to conform in order to exclude actions that could create danger for the entire group rituals such as collectively committed illegal acts function as additional protective mechanisms functional equivalents to these group processes are observed in connection with both targeted attacks in schools and jihadi attacks and can be described as private rituals and selfcontrolling behavior clandestine planning in small groups within small groups the group hierarchy and dynamic facilitates the escalation process towards violent attack in the case of 3 ter 4 ter 5 ter and 6 ter preparation activities eventually oust more or less all everyday life activities of the members several months before the arrest during their training in a terror camp run by jihadist militants in pakistan 3 ter 4 ter 5 ter and 6 ter were ordered to execute an attack on german territory after their return from the middle east the group procured seven hundred kilograms of chemicals and stored them in a garage rented for that purpose they also moved to a holiday rental hundreds of kilometers from their respective places of residence in order to finish their bombmaking with only a few exceptions the perpetrators immediate social environment was not privy to their plans wiretap transcripts show that the group had quite ambivalent attitudes towards their mission at first they were against attacking civilians in germany and they desired to fight and die for their brothers and sisters at the front rather than kill innocents in their home country but the group managed to overcome these doubts by reinforcing and controlling each other for example they imagined how the interior minister would appear on camera after their attack and talk about the most devastating terrorist plot since 911 referring to the popular music casting show 5 ter stated during the preparations that he felt like he was on terrorist idol and that he was expecting to receive the death penalty at least deportation to guantanamo collins describes such dynamics during the perpetrators preparation as clandestine excitement we also identified similar processes of isolation and clandestine excitement in the cases of 1 ter and 2 ter as the dominant part of the terrorist dyad 1 ter was eager to isolate 2 ter from his fellow students while accelerating his radicalization while preparing their suitcase bombs they withdrew completely from their social environment like 3 ter 4 ter 5 ter and 6 ter they had an exact idea what would happen after their attack their bombs were to explode on the ground while they were sitting in a plane flying towards the middle east they adjusted the detonators of the explosive devices according to these plans with their attack they wanted to recommend themselves to terrorist organizations as recruits n böckler et al comparison of school attackers and jihadi attackers clandestine planning by isolated individuals similarly to clandestine planning in small groups and dyads isolated actors also build a clandestine space where their fantasies experience confirmation and recognition upon which further cognitive escalation and selfcommitment play out and where emotional preparation for the act occurs for school attackers collins describes a deep backstage where young people create a ritualized hidden arsenal around which their fantasies and activities revolve their knowledge of the illegality of the arsenal and their own associated potential to kill creates a clandestine excitement that ultimately supplies the emotional energy for carrying through the attack itself we found evidence for such hidden arsenals in several cases perpetrators procured pistols and trained secretly in two cases they built pipe bombs in most cases the acquisition of weapons was illegal and the perpetrators created hiding places which they visited periodically ownership and handling of real weapons can itself have an escalating and urgencyproducing effect where the weapons are experienced as sensually stimulating they also symbolize the possibility of turning fantasies of power and vengeance into reality another typical element of clandestine planning by isolated individuals is the ritualized writing of diaries in which they absorb themselves in their fantasies and planning thoughts sometimes fantasies and writings revolve around public reactions after the planned attack i will be the first to go on a rampage with a blank cartridge pistol it will restart a discussion about our gun laws but its all the same to me in five out of seven school attack cases we found such writings showing a ritualized identification with and glorification of the perpetrators of the columbine school shooting in littleton in 1999 former school attackers are the holy pillars on the private altars of most of the subjects in our school attack sample fans and imitators form a virtual community in social networks and discuss the possibilities of violent acts and the pros and cons of different weapons strong selfcontrolling behavior can also be observed in cases of isolated individuals but in forms that are less consistent and characterized by ambivalence between safeguarding the secret and public intimation alongside secret planning and private rituals the new selfconcept is also expressed outwardly and reflected in visibly altered behavior for which the term leakage has become established in our analysis we found that later school attackers created poems drawings and even theater plays or showed weapons they already possessed to others these communications and the displayed personal redefinition also generate enormous pressure to carry through the attack because any deviation from the leaked plans and the new role would be experienced as weakness and potentially interpretable as confirmation of the earlier selfdefinition as victim one could say that leakage creates a selfobligation to carry through the attack of course leakage must never go as far as to create a danger of the secret attack plans actually being discovered for this reason we also always observe selfcontrolling behaviors in lone actors such as precautionary measures diversionary maneuvers and deception strategies that serve to keep others from discovering the deep backstage as such leakage describes the perpetrators game of hinting at the secret plans to others while at the same time warding off those who come too close to discovering the secret which heightens the secret excitement such leakage can also be identified in connection with lone actor terrorists as hoffmann glazocik roshdi and meloy relate especially with lone actor terrorists the desire for selfprojection often overpowers the tactical need for discretion where the attack planning is not subject to the discipline of a group while 7 ter for example withdrew more and more from family peers and friends he started to glorify martyrdom and violent jihad via the internet furthermore he listened to islamist nasheed songs that told him to turn away from all infidels about one year before his attack he declared his hatred against the west in internet chats and forums where he openly sympathized with terrorists and described the united states as personified evil and toyed with the idea of joining the mujahideen in iraq few months before his attack he started to delete all his nonmuslim friends on facebook and added to his profile quite a number of strangers whose facebook page indicated some kind of association with islam during this time he focused more and more on the ideological world while other spheres of life receded into n böckler et al comparison of school attackers and jihadi attackers the background as also reflected in the amount of jihadist content he downloaded from the web escalating triggers even if the deep backstage selfobligation and escalation mechanisms described above drive developments to the point of violent action there is no automatism whether an attack is actually carried out will depend inter alia on concrete events that may appear in very different forms both for school attackers and jihadi terrorists the first and most important trigger is events that generate pressure to act such as events that suggest a concrete external danger of discovery of attack planning or internal pressure resulting from the escalating dynamic in small groups in the school attacker sample there is one case where the perpetrator was apprehensive about the discovery of his weapon arsenal by law enforcement two perpetrators feared disclosure of their violent plans by classmates 3 ter 4 ter 5 ter 6 ter attracted the attention of the police when 4 ter and 6 ter reconnoitered a possible target for their attack a us military base this led to police observation and house searches although 3 ter 4 ter 5 ter and 6 ter knew about the surveillance efforts they nevertheless continued with their attack plans besides pressure from law enforcement we also identified other influencing events that escalated the situation for later perpetrators for example termination of employment or stressing social events secondly we must consider events in the social setting that radicalized perpetrators perceive as legitimization of their ideological beliefs and attack planning these can include events experienced as a massive attack on the ingroup and its ideology such as acts of violence vilification and abuse from the outgroup heitmeyer argues that such signal events exhibit strong potential for emotional and moral outrage and as such are certainly suited to mobilizing individuals and groups to commit violence in the case of school attacks in four cases the perpetrator experienced a disparagement or social reinforcement that was interpreted as a legitimation for the attack while 3 ter 4 ter 5 ter and 6 ter intensively discussed the legitimacy of an attack as revenge for western intervention in the middle east 1 ter for example convinced 2 ter that the publishing of mohammed cartoons in german newspapers was one of the severest possible insults against the muslim community 1 ter framed an attack as a necessary retaliation against western society shortly before his attack 7 ter the lone operator viewed two videos on youtube the first showed the lifeless but smiling faces of martyrs accentuated by a heroric nashid the second showed a scene from the movie redacted in which us soldiers rape a muslim teenager 7 ter who was not aware that he was watching a hollywood movie was unable to get this scene out of his head he was sure that it was sign from allah who wanted 7 ter as a proof of his faith to protect his sisters from further abuses the next day 7 ter killed two american soldiers at a german airport especially in the case of school attackers retraumatizing events may reactivate earlier negatively experienced emotional states or negatively connoted selfimages for example a recent slight or subjectively experienced injustice can reactivate the earlier traumatic experience of loss of status and trigger the actual intention to carry out the attack in the school attacks sample there are two examples in which the later perpetrators again experience bullying and social exclusion reactivating their earlier experiences and triggering execution of the attack finally perpetrators may experience loss events as triggers one example would be the end of an important relationship that previously represented a social connection outside the clandestine radical arena all four trigger types help the perpetrator to view the act of violence as necessary justified inevitable and meaningful the decisive concrete trigger or combination of events in a particular case can generally only be determined retrospectively attempts to identify generally applicable triggers for acts of violence are therefore pointless instead it must be assumed that in each individual case the interaction of individual decisions positive and negative feedback processes changed perception of opportunity costs and biographical breaks become crystallization points for dominant action patterns and paths towards violence demonstrative acts of violence for a complete understanding the situations of violence have to be described as triads of perpetrator victims and third parties a closer look at the concrete situations of violence reveals that all perpetrators in both groups chose their victims for their symbolic significance hence we describe targeted attacks in schools and acts of terrorism as demonstrative acts of violence demonstrative violence seeks to spread terror to earn respect to dispel boredom it has a genuine social meaning violence in this context is selfpresentation and selfcommendation with respect to the communicative meaning of the acts two aspects need to be distinguished firstly the communicative meaning can be described as an expression of personality where the perpetrator seeks to present their own personal andor social identity and to generate social recognition some terrorism researchers have argued that a terrorist attack is a kind of altruistic violence where an individual becomes a faceless ideological soldier for a groups cause however jihadists are eager to offer possibilities for recruits to become both a soldier for the cause and at the same time famous as an individual at least within the extremist networks but often also within society through intense media coverage secondly the acts of violence under consideration here are directed forms of communication they are bound up with a message which the perpetrators want to share for example when the perpetrator refers to ideologies draws attention to injustice seeks to spread fear and panic or hopes to mobilize others to do the same the success of the act thus depends from the perpetrators perspective largely on the responses of the social environment so that the perpetrator must ensure that hisher message is understood for this reason perpetrators generally seek to shape the public interpretation of their actions through manifestos letters videos and personal writings for our sample that was especially true of the school attackers while the jihadi attackers mainly focused on attacking symbolic public targets to spread their message however at the same time most of terrorist attackers could rely on an extremist organization to take responsibility for the attack while 3 ter 4 ter 5 ter 6 ter and 7 ter focused their attack on american soldiers 1 ter and 2 ter chose to attack civilians in general after 1 ter and 2 ter had excluded a famous german bridge and a soccer stadium as potential targets for practical reasons they decided to focus on passenger trains inspired by the alqaeda attacks in madrid and london discussion to our knowledge this is the first study to empirically analyze the similarities and differences between school attackers and jihadi terrorists in germany in the period of 2000 to 2013 using police files and court judgements the sensitive concept proved to be fruitful for the comparative analysis of the developmental pathways towards targeted demonstrative violence while the pathways of the perpetrators in both groups were quite similar in general terms the analysis also brought to light significant variations between the groups in most of the categories findings show that the perpetrators perception of reality and developmental pathway may be influenced by mental abnormalities but only in one case was here any indication of mental disorder reducing the ability to exercise control in the attack situation all perpetrators in both groups suffered from grievances in at least one of three socializing contexts accompanied by fundamental incongruences between their realself and idealself in most school attack cases and some jihadi terrorist cases grievances culminated in personal crises that were subjectively perceived as highly significant and triggered further maladaptive development while the subjective experience of grievance was identified in all cases its character differs between the groups school attackers mostly suffered from parental demands and humiliations by peers and teachers while jihadi terrorists suffered from a lack of role models in their family identity diffusion between two cultures and employment problems these differences may also have to do with the fact that the subjects in the jihadi terrorist sample are on average about five years older than the investigated perpetrators of targeted violence in schools in other words the two groups are at different developmental stages while the development of a gender identity a consistent system of norms and values and the establishment and structuring of social friendships are central developmental tasks in the adolescent phase the fostering of economic independence career development and participation in cultural and political life are important tasks of adult life when we understand radicalization in a broad sense with wilner and duboulos as a personal process in which individuals adopt extreme political social andor religious ideals and aspirations and where the attainment of particular goals justifies the use of indiscriminate violence it is noteworthy that individuals in both groups orientate on politicalcultural scripts with violent content which obviously offer a possibility to express themselves and to cope with perceived grievances and with central developmental tasks in this view perpetrators who commit symbolic targeted violence in schools also experience a process of radicalization on their developmental pathway towards violence taking the personal grievances of both groups into account it becomes clear that the choice of an islamist script on the one hand and a school shooting script on the other is biographically reasonable in either case for the further developmental pathway it is crucial that the confrontation with a suitable violent script occurs in the right moment when the individual is seeking a solution for their stressful situation be it short term or longterm stressors against this background it is important to note that radicalization processes never take place in a social vacuum this is true for jihadi terrorists as well as school attackers while real world social networks and friendship ties played a central role as radicalizing social contexts for jihadi group terrorists virtual social networks and processes of parasocial identification were crucial for school attackers and the only lone actor terrorist in the sample the social negotiation of cultural scripts and constant feedback within radical social spaces accompanied the lowering of individual thresholds for use of violence in both groups especially for individuals with stronger social anxiety virtual contexts offered a possibility to approach a radical group from a state of social isolation while close friendships social involvement and the attractiveness of leading a real world group were central motivations to go further along the path towards violence for the terrorist subjects the desire to cope with social disrespect and failure and to gain social recognition and significance were the armed with several knives and an axe a 13year old girl lights a fire in the school hallway and threatens to kill classmates she is arrested without injuring anyone one and a half year after the first event after a stay at a psychiatric clinic she attacks her classmates at her new school using her fathers gas gun sa school attack four perpetrators aged 22 27 and 28 are arrested while constructing explosive devices to attack us targets two of the perpetrators are sentenced to 12 and 11 years for membership of a foreign terrorist organization conspiracy to mass murder and coercion one of the conspirators who tried to shoot a police officer during his arrest is also convicted of attempted murder and also sentenced to 12 years in prison the fourth perpetrator who was entrusted with acquiring detonators is sentenced to five years in prison 7 ter 2011 21yearold man with a handgun shoots two us soldiers dead at frankfurt airport and severely wounds two others sentenced to life in prison for two cases of murder and three cases of attempted murder in conjunction with grievous bodily harm ter terrorist attack drivers for the school attackers and the lone actor terrorist in both groups the pathways were consolidated by dynamics of clandestine planning and excitement accompanied by the restriction of social interactions to radical social spaces while small group dynamics mechanisms of group control and mutual encouragement fostered the radicalization processes of the jihadi terrorist subjects social withdrawal private rituals and leaking were identified as equivalents for the lone actor terrorist and school attackers especially the latter mechanisms stimulated fantasies of omnipotence and a new perception of the self in distinction to society while radical spaces become gradually central for the selfworth of the later perpetrators the perception of ongoing grievances everyday challenges moral outrage and in some cases the stress of law enforcement surveillance served as escalating triggers and increased the pressure on subjects to prove themselves according to the new and redefined violent identity in the last stage the execution of targeted violence serves as an initiation ceremony to join a series of other ideological motivated avengers and to demonstrate the radical identity ultimately and irreversibly on a public stage from an operational point of view it makes strong sense to assess terrorist attacks and targeted violence in schools using the concept of demonstrative violence which allowed us to identify the same core stages with different dimensional manifestations in the perpetrators developmental pathways for both phenomena that indicates that the two phenomena are not categorically different therefore we agree with borum et al that we should stop devoting resources to scientific definition exercises regarding the number of perpetrators that can be evolved the kind of outside support which is acceptable or the purity of the political respective ideological motive that is necessary or reasonable to classify an act of violence as terroristic attack or a rampage as hybrid characteristics are rather the norm than the exception borum et al argue that it would be much more effective to view these factors along a continuum instead of forcing unnecessary eitheror choices we propose the same logic for the developmental stages defined in the present paper future efforts should focus on identifying and categorizing the characteristics of warning behaviors at each stage and using them for the purpose of early detection but the model might also be useful for planning effective case management strategies in the deradicalization and threat management context as the localization of a person of concern in the different stages and subdimensions of our pathway model helps to understand the inherent logic of a case the needs the individual links with hisher behavior and the social environment which influences the pathway actively or passively moreover the model could sensitize a case manager for potential points of intervention during a process of escalation limitations and outlook especially in the context of the socalled islamic state terrorism is a very dynamic phenomenon we already know that a significant number of the young people who travelled from germany to iraq and syria in order to join jihadist militias between 2013 and 2015 were minors there is anecdotal evidence that social pressure and influence played a greater role in their decision to fight or to commit attacks in their home country than for the older perpetrators in our sample who showed significant intrinsic motivation nevertheless we also have to understand the role and pathway of female attackers like safia s who tried to kill a policeman at hannover central station by stabbing him in the neck radical female jihadi networks and the recruitment of women are also playing an increasingly important role however as most of the criminal proceedings are still pending researchers have no access to the related police files or court judgements at present this is also the case for the vast majority of lone operator attacks committed in 20152016 when the islamic state was forced to change its strategy and called on muslims to stop emigrating to the caliphate and to fight the infidels in western countries instead but current developments indicate that the overlap between terrorist violence and school attacks is increasing rather than decreasing without doubt it will be a central task of future research to test this hypothesis against a reliable database and it will be a central topic for future development activities in the domain of preventive interventions as we have developed the presented empirically grounded model of the developmental pathway towards demonstrative violence using qualitative comparative analysis it is open to change and optimization on the basis of additional cases analyzed through the lens of the current work we should also ask whether it is possible to categorize other phenomena of targeted violence under the concept of demonstrative violence in the long run larger reliable data bases and control groups would be necessary to properly validate a concept like demonstrative violence authors notes target research project bmbf funding code 13n12646 bio sketches nils

analysis of incidents over the past ten years in germany reveals that the boundaries between targeted attacks in schools and terrorist attacks are starting to blur böckler leuschner roth zick and scheithauer 2018 recently presented a set of hypotheses about similarities between the developmental pathways of school attackers and lone actor terrorists to date there is only a small body of empirical research comparing these two forms of targeted violence in depth in order to fill this gap this article presents findings from a qualitative analysis of prosecution files comparing the developmental pathways of german school attackers n 7 age range 13 to 23 and jihadi attackers n 7 age range 21 to 28 years who committed their attacks between 2000 and 2013 using theoretical coding and constant case comparison the contribution shows that the two phenomena have overlaps in which developmental processes and social mechanisms are similar both school attackers and jihadi attackers frame their act of violence using cultural scripts and perform the attack on a public stage where victims are attacked not on the basis of personal conflicts but because of their symbolic meaning taking into account the similarities in the perpetrators developmental pathways the authors propose that it might be more fruitful from an operational perspective to discuss severe target school violence and terrorist attacks under a common concept of demonstrative violence than to artificially assign them to exclusive classes of violence

vol 64 no 2 2021 introduction suburbanization is a part of urban development involving the lowincome the poor and those living in rural areas without planning control or adherence to urban planning rules and regulations 1 suburbanization is a social phenomenon that has consequences such as poverty crime exploitation of child labor the weakening of the middle class and domestic violence suburbanization can be regarded as a major disaster that entails thousands of injuries and crises serious social damage occurs more in suburban areas than anywhere else including domestic violence against women and children the world health organization defines violence as the use of mental or physical force to force threaten or harm another person group or community that causes physical or psychological harm deprivation or death 2 domestic violence against women includes any physical sexual or emotional abuse imposed on women in family relationships 3 domestic violence is recognized as the most common type of genderbased violence and is a particular social and health concern 4 violence against women is purely cultural despite initiatives by national and international organizations violence against women is on the rise worldwide 5 in response to the lack of comparable data on the prevalence and impact of violence against women the who in collaboration with international and local partners conducted a large study in 10 countries using representative samples from 15 studies among 24000 women the results of a multicountry study on womens health and domestic violence against women showed that between 1571 of women aged 1549 in a relationship experienced physical or sexual violence by a partner during their lifetime most studies reported an average prevalence of violence between 3060 6 other studies found that women with a history of physical or sexual violence had significantly higher health problems greater pain poorer health greater anxiety and higher suicidal thoughts than women who had not experienced violence 7 a recent comprehensive review by the who acknowledged that the global prevalence of physical or sexual violence by a sexual partner is 30 among all women the highest prevalence is in africa the eastern mediterranean and southeast and eastern asia where approximately 37 of women experience partner violence 8 the results of various studies indicate that the following social determinants and factors are independently associated with domestic violence low age of women length of marriage higher education in women husbands low education working spouses military occupation fewer children multiple spouses smoking spouses aggressive spouses chronic illness in women or their spouse and inadequate family income 9 according to the who model the social determinants of health are socioeconomic structural factors such as income education employment social class gender race and ethnicity intermediate factors such as living conditions behavioral and biological factors such as physical activity alcohol and tobacco use and healthrelated factors 10 is there a solution to this problem policies and programs based on gender empowerment analysis attitudes and norms that reject violence and promote gender equality as well as coordinated efforts to promote womens activism for a nonviolent life are essential principles of sustainable investment in preventing violence against women 11 in addition to the many social economic cultural security and environmental problems in metropolitan areas suburbanization has caused the rise and spread of domestic violence against women and continues to increase since there has been no research on the social determinants of domestic violence in suburban women despite a considerable amount of domestic violence against suburban women the current study aimed to investigate the social determinants of domestic violence in suburban women and suggest measures to eliminate its contributing factors so as to help this segment of society fatemeh abdi et al domestic violence against suburban women inclusion and exclusion criteria inclusion criteria include all english and persian studies published between 2009 and 2019 that were found in databases based on mesh keywords and studies that in addition to expressing the prevalence of general domestic violence or types of domestic violence also addressed relevant social factors related to domestic violence all in suburban areas with married or single girls and women of different ages attending the study voluntarily exclusion criteria included articles in languages other than persian and english languages case reports comments letters studies focusing solely on the social factors related to domestic violence without addressing their prevalence women who were aware of their rights and domestic violence and women who did not want to cooperate study selection the initial search yielded 733 results the eligibility of these papers was independently evaluated by two authors and any disagreements were resolved by consensus in the first stage 400 papers were excluded due to being irrelevant or duplicated after reviewing the titles and abstracts of the remaining papers 177 more papers were excluded in the evaluation of the full texts 42 out of the remaining 99 articles were excluded due to being ineligible finally a total of 30 eligible articles were reviewed quality assessment the strobe statements were applied to evaluate the quality of studies the checklist items focus on reporting how the trial was designed analyzed and interpreted the strobe statement an authoritative tool consists of a 22item check list the checklist items focus on reporting or evaluating different sections of observational studies 1213 the jbi checklist was used for qualitative studies data extraction two authors independently performed the study selection and validity assessment and resolved any disagreements by consulting a third researcher the first author name publication year study design sample size study region age social determinants of domestic violence total prevalence of domestic violence physical violence emotional violence sexual violence economical violence verbal violence and quality score were extracted and entered into the analysis results after evaluation 30 articles were selected as eligible the types of articles were qualitative quantitative and mixed method a total of 18723 women living in the suburbs and in different age groups participated in the study the frequency of countries in which the articles were conducted is as follows india bangladesh nigeria nepal uganda iran south africa pakistan and kenya prevalence of domestic violence in suburbs domestic violence was perpetrated by various individuals such as the husband the spouses family other members of the wifes family and relatives the most common perpetrator was identified as the husband of the 30 studies 23 cases reported that the prevalence of general domestic violence among women of different ages ranged from 237378 in suburban regions of different countries the lowest and highest prevalence were in india and bangladesh respectively twenty studies also reported the prevalence of physical violence as 1154616 the different types of physical violence that were dealt with in the studies included slapping pushing beating hitting kicking firing pulling twisting the hand and throwing fourteen studies reported the prevalence of emotional and psychological violence as between 78843 the different types that the studies addressed included fear of the spouse verbal disputes the use of derogatory rhetoric intimidation lack of meeting basic needs and insults thirteen studies reported the prevalence of sexual violence as approximately 08588 in addition there were questions about forced sexual relations of any kind three studies reported economic violence with a prevalence ranging from 137437 moreover there were cases where the wifes financial needs were not being met by the husband four studies also exclusively focused on verbal violence with a prevalence of 3321861 verbal violence also included humiliating a person alone or in front of others threats of divorce doubting using abusive rhetoric to address the woman asking for a dowry and insulting the womans personality social determinants of domestic violence in the suburbs of the 30 studies 28 reported factors that cause domestic violence against women according to the who model factors related to domestic violence can be divided into structural and socioeconomic factors including education employment economic status social class gender race culture intermediate factors including living conditions psychological conditions and social conditions behavioral factors and factors related to the health system structural factors these factors include low age at marriage low literacy or illiteracy of woman not doing household chores properly financial issues and low socioeconomic status gender inequalities and patriarchal gender norms not cooking properly or not cooking according to the husbands desire dowry issues such as dowry demand or low dowry not being able to bear a male child low level of spouse literacy poverty working women and earning an income leaving the household on any pretext without prior permission from husband duration of marriage 5 years and more women belonging to families with low per capita income extramarital relations by woman unemployed women number of children and neglecting the children according to the spouse neglect of children justifying wife beating instigation by motherinlaw affairs related to the husbands family and doing things disfavored by the inlaws number of family members husbands unemployment talking to neighbors fear of losing relationships not empowering women in decisionmaking talking to unrelated males and family type intermediate factors the frequencies of these factors included husbands addiction to alcohol and drugs verbal disputes and conflict with husband refusal of sex depression perceived disobedience infertility multiple sex partners maladaptive behaviors in adolescent girls physical trauma disability and inadequate household health healthsystemrelated factors one study noted womens lack of legal protections two studies also reported domestic violence without a reason discussion domestic violence is a major health problem throughout the world that although not yet well recognized is still associated with uncertainty and many taboos for women and can impact every woman regardless of her age culture and socioeconomic status 44 in this systematic study 30 articles on domestic violence and related social determinants were studied based on the who model among domestic violence types physical violence was the most prevalent in 20 cases emotional violence in 14 cases and physical violence in 12 cases alhabib et al 45 in a metaanalysis study stated that violence against women has reached epidemic proportions in many societies and it appears that all ethnicities nationalities or socioeconomic groups are affected by this phenomenon this finding is consistent with the study by zakar et al 46 who found that the highest prevalence of reported violence is related to emotional violence a study conducted by dolatian et al 47 in one iranian city found that rates of emotional violence are higher than those of physical violence 812 and 404 respectively but a study conducted by sheikhan et al 48 found that physical violence was 347 more prevalent than emotional and sexual violence the results of a national study by spanish researchers surveying 26042 women who suffered violence in 2006 also found the prevalence of sexual psychological and physical violence against women to be 7 185 and 188 respectively 49 in their study brazilian researchers reported the prevalence of physical psychological and sexual violence as 418 337 and 143 respectively which is consistent with recent findings 50 but some studies attributed the difference between prevalence of physical violence with emotional and verbal violence to the greater salience of physical violence than emotional violence the existence of respective legislation and the reluctance of some women to speak about physical violence for various reasons such as taboos 51 various studies have identified several factors associated with domestic violence in a recent study based on the who model among structural determinants economic social educational level and gender inequalities showed the highest correlation with violence education of the spouse and women is cited as a protective factor against violence the higher the education of the spouse the better his behavior with the woman due to his understanding of social and family duties which reduces violence the education level of women at the individual level has a strong association with violence partly due to living standards although today for a number of reasons including the acceptance of mistreatment of women at the social level the protective effect of education has been somewhat reduced 52 education level can also contribute to improving socioeconomic status through its role in assisting in finding the right job thereby reducing the violence that occurs because of the inappropriate status of this factor 10 recent findings are in line with the findings of moafi et al 53 who also found that structural factors such as socioeconomic status education social class and gender are related to the prevalence of violence in addition they found that womens education and employment were inversely related to domestic violence similar to the results of the present study fallah et al 54 reported education employment age of marriage and income as the most relevant factors among the structural factors related to domestic violence inappropriate income and spouses unemployment leads to more presence of men at home and marital conflicts due to financial problems and subsequent psychological impacts conversely having a job financial independence and optimal economic status are protective factors against types of violence 55 among the intermediate determinants examined in the articles inappropriate health behaviors such as alcohol and drug abuse sexual dissatisfaction inappropriate environmental conditions and mental disorders showed the highest associations with domestic violence a study conducted by castro et al 56 found that the most important predictor of domestic violence was alcohol use other studies have confirmed findings consistent with the results of the current study and it seems that this factor as a situational variable exacerbates conflicts between couples 5758 while drug and alcohol use by women might be a negative adaptation to violence and its resulting stress it can also anger the husband and exacerbate the violence 59 in a study conducted by moafi et al 53 alcohol use was associated with domestic violence although its use by woman was unrelated another intermediate factor was sexual dissatisfaction hastuti et al 60 found that women who had sexual dysfunction followed by sexual dissatisfaction were 4 times more likely than other women to experience domestic violence ulloa and hammett 61 reported a correlation between an increase in the proportion of domestic violence and sexual dissatisfaction they stated that the lower the level of sexual satisfaction the higher the probability of domestic violence according to babaie 62 when there is disagreement or difference between spouses conflicts were arise without satisfactory sex the stability of marital relationships is endangered thus researchers believe that marital satisfaction is always subject to sexual satisfaction 63 in the who model the health system determinant is observed both separately and alongside structural determinants in the present study one study points to the lack of legal implications for women by respective organizations and the incidence of domestic violence the highest frequency of violence against women occurs in the family environment and through their marital partner some countries have helped the judiciary to decide on men who commit domestic violence against their spouses this has led to changes in laws in some countries in line with international guidelines to better protect women against domestic violence 64 65 66 67 innovative and novel interventions and policies are now available around the world to reduce violence against women however an integrated and coherent approach is still needed to bring together all national and international nongovernmental organizations to achieve sustainable social change given the wide range of perpetrators of domestic violence against suburban women it can be stated that domestic violence is almost always widespread in developing countries and the factors affecting it can be prevented by health planning and raising awareness in these areas the health systems of these countries should pay special attention to health planning of women as the family foundation in the suburbs and promote their physical and mental health with particular attention to protection of vulnerable women and preventing violence against women the social cultural and religious taboos in the suburbs against expression of violence against women in these areas as well as various cultural and religious factors in different parts of the world offer a different range of domestic violence that make it difficult to judge ethical approval this study was approved by the social determinants research center of alborz university of medical sciences with ethical code irabzumsrec1398194 patient consent none

in addition to the many social economic cultural security and environmental problems in the metropolitan areas suburbanization has led to the growth and spread of domestic violence against women and is still increasing different social determinants can play a role in violence against suburban women so this study was designed to investigate the social determinants of domestic violence in suburban women of developing countriesaccording to prisma guideline the keywords which were determined considering mesh were searched in google scholar medline sid web of science pubmed scopus and science direct with the 2009 to 2019 time limit strobe checklist was used for evaluating quantitative studies and jbi for qualitative studies finally 30 high quality studies were includedthe prevalence of general domestic violence among women of different ages was reported between 237378 in the suburban regions of developing countries the prevalence of physical emotional and psychological violence was about 1154616 and 78843 the prevalence of sexualeconomic and the verbal violence was about 08588 137437 and 3321861 the most common factors affecting violence against women were the structural factors of early marriage the husbands addiction to alcohol and drugsgeneral domestic violence and its various types are prevalent in different parts of the world and the factors affecting domestic violence such as age marriage age low literacy husband addiction to alcohol and drugs are all things that can be prevented by special health planning in these areas to improve womens health and thus prevent violence against suburban women

introduction the outsiderwithin is a phenomenon in which a specific group is marginalised and relegated to the periphery due to their gender or other factors the oppressed group by the capacity develops the power to write about traversing various spaces they occupy and tell people by collecting the inside knowledge and happenings coined by patricia hills in 1986 outsiderwithin describes people who have particular knowledgepower relationship which is given to them due to the special status that their differences bring to them they have a unique perspective because of their intersectional identities which includes their gender caste class race and religion these agents of interculturality partake to give an active role in the critical construction and reconstruction procedure and to bringtell experienceknowledge of marginality at the public forum standpoint is a social theory that talks about oppressedmarginalised groups in the broader perspective of resistance against the power structure and hierarchical power prevalent in society the origins of standpoint theory can be traced in hegels analysis of the masterslave relationship and his elaboration on the notion that the slave can achieve liberation through consciousness developed through the constant struggle with the master as harding argues standpoint focuses on the historical and social locatedness of knowledge… collective political and intellectual work can transform a source of oppression into a source of knowledge and political liberation makes a distinctive contribution to social justice the emergence of feminist standpoint theoryfeminist perspective can be traced back to the 1970s and 1980s during which it gained recognition as a critical feminist theory that explores the intricate connections between knowledge production and power dynamics the idea has been posited as a means of granting agency to marginalised collectives acknowledging the significance of their articulations and fostering a counterhegemonic awareness the concept of the standpoint has been examined and elucidated by feminist theorists resulting in the evolution of the theory into a comprehensive framework that encompasses various approaches these approaches include donna haraways analysis of situated knowledges nancy hartsocks feminist historical materialist perspective patricia hill collins black feminist thought and dorothy e smiths notion of everyday world sociology for women these scholars argue that women perceive and interpret the world differently thereby challenging existing perspectives according to narayan it is argued that women possess a distinct form of knowledge when a marginalised group obtains a collective voice it establishes a position that generates new understanding and the philosophy that encourages social wellbeing and justice in academia standpoint could be traced to the rise of subalterns or proletariats particularly in the marxist movement where it is built in the form of resistance to encapsulate political consciousness empowerment and intellectual achievement it is useful to analyse intersubjective discourses since the body of work claimed that authority is rooted in a persons knowledge and viewpoints as well as the power that such authority wields and that it is utilised to speak the truth and perspective from a social position and location women being the subaltern claim that their domain needs to be explored more in addition to experiences and perspectives underlined for equal opportunities as dorothy smith points out in the everyday world as problematic a feminist sociology women have been disregarded and objectified by sociology and are turned into other sociologists have always ignored and decentered the womens experience the standpoint theory questions the economic exploitations of womens labour the political denial of their rights and the way society assigns them a negative cultural and social image collins calls for the inclusive scholarship that rejects knowledge that dehumanises and objectifies people women are not credited for their invisible labour socioeconomic positions and responsibility to run the home the theory contends that marginalised peoples experiences reveal underlying problems that must be voiced brought to light and explained these problems can inspire research and raise questions about ways of life social structures dominant social communities bigotry and the assertion that has initially counted as knowledge since the social structure is defined and generated by the dominating groups mens society cannot understand how dalit women suffer general exclusion and threat of power relation the term outsiderwithin is employed to understand the condition of dalit women in perspective and not as things in themselves the same object event or here as a class or sociocultural group in themselves ie dalit women may appear differently to different observers and actors depending upon their positionality and location in the societal hierarchy dalit women have a distinctive advantage as an outsider within because their identity centred around marginalisation which allow them to seeexperience facts or realities that may not be visible to others the concept of outsider within argues that dalit women produce their own feminist standpoint exceptional on self family society and culture analysing the significance of dalit agency they interlock multiple themes such as writing on selfdefinition and selfvaluation systematic and structural oppression and cultural production while talking about themselves culture and society they hold their outsiderwithin vision which shapes their perspectives dalit women writers employ their social position to establish a dalit feminist standpoint effectively amplifying the voices of the socially marginalised these voices possess a heightened comprehension of social reality due to their firsthand experiences of marginalisation aligning with the fundamental principles of standpoint theory in this regard i have chosen sangati by bama and the prison we broke by kamble two of the influential works in dalit literature to discuss how marginalisation functions not only through uppercaste people but also through dalit men their marginalised state in society gives them a standpoint as an outsiderwithin this becomes apparent in their representation of the self as well as the community the centrality covered in this paper is how dalit women use their outsiderwithin status to assert their identity and bring a consciousness in transforming from voiceless to voiced besides this writings by dalit women converge the caste as well as gender issues the writers of the chosen texts have a strong disposition towards the feminist ideology as gender when combined with caste especially the lower caste makes these women particularly vulnerable in writing their story of haplessness and limitations they have transversed and metamorphosed it into a saga of struggle for survival and selfhood articulating and asserting the self for there to be a need for identity there needs to be an assertion baby kamble in her forward to the jinua amachi claimed how she is proud of being called a mahar as she puts it i love our caste name mahar it flows in my veins in my blood and reminds me of our terrific struggle for truth baby kambles assertion of pride in her mahar identity is reclaiming of a term that has historically been used to demean and dehumanise dalits by openly embracing her caste name she is challenging the stigma associated with it and turning it into a symbol of resilience and struggle her claim that her name flows in my veins in my blood emphasises the deep connection she feels to her communitys history of fighting for justice through this assertion she is reframing the narrative transforming her identity from a source of shame to a source of strength this sense of pride and ownership can be seen as a form of resistance against the oppressive norms that have sought to suppress dalit identity in the same way for laxmi holmstrom sangati teases out a positive cultural identity as dalit and woman which can resist uppercaste and upperclass norms holmstroms comment regarding sangati highlights the texts capacity to facilitate the formation of a constructive cultural identity the literature portrays several narratives and accounts that collectively reveal a complex dalit identity which covers the intersectionality of gender caste and religious affiliation the construction of this identity is established via resistance against the societal standards enforced by privileged castes and classes the narratives presented in sangati serve as a medium through which dalit women can articulate their challenges and desires so constructing a counternarrative that challenges prevailing discourses and fosters a sense of empowerment among dalit individuals enabling them to accept their complete identity without any sense of guilt or reluctance by writing about their experiences bama and kamble have crafted out a positive cultural identity for themselves as well as their community their assertion for identity and pride in themselves stems from ambedkars call for selfrespect the very fact that kambles the prison we broke talks of the ambedkarite movement highlights the call of these writers for selfrespect besides this the writings by dalit women writers have a unique positionality in voicing their experiences these writers not only talked of the experiences but also of the thoughts that shape the lives of dalit women however while recounting their experiences they are selfreflective and selfcritical as well these writings bring out not the depraved women but valiant and dynamic women who revolt to protect their selfrespect the revolt of dalit women is not personcentred but societycentred and their courage to fight resoluteness rebelliousness is the very essence of their life dalit women writers possess a distinct positionality in articulating their lived experiences the memoirs of dalit women beyond mere depictions of difficulties and instead dive into the profound contemplations that influence their life these authors demonstrate the diverse facets of their identities and experiences highlighting their ability to persevere and their reluctance to adopt a victim mentality significantly the narratives produced by individuals are not limited to personal experiences but rather encompass and address wider societal concerns promoting the notion of communal empowerment the crux of the dalit womens uprising is not rooted in individual grudges but rather in their valiant resistance against systemic inequities throughout society the narratives of these individuals depict them not as passive recipients of victimhood but rather as courageous and active agents who strive to uphold their selfworth and honour the aforementioned transformation in storytelling deconstructs and portrays a more precise and empowered life of dalit women the writings of dalit women exemplify the profound impact of literature in forming ones sense of self and cultivating feelings of dignity and empowerment the act of proclaiming ones identity serves as a kind of resistance against oppressive structures that have historically aimed to erase or undermine the value of dalit experiences the arguments made by writers such as baby kamble and books like sangati contribute to the wider movement of dalit literature by challenging stereotypes promoting empowerment and creating platforms for the recognition and appreciation of dalit voices the literary works produced by dalit women writers are in accordance with the ideas espoused by ambedkar emphasising the need of selfrespect these narratives effectively utilise personal experiences to question existing societal standards and promote a constructive cultural identity by use of their narratives these individuals not only reconstructed their own personal identities but also made significant contributions to a wider movement aimed at achieving justice equality and empowerment within the dalit community narratives of humiliation and survival dalit female autobiographies or testimonies are laced with the odyssey of the survival of the dalit in the face of abject humiliation women the second sex have the secondary status in society gender and belongingness to the dalit or depressed class make dalit women the weakest in the society as the patriarchal nature of indian society does not recognise the rights of women and as a member of the lower caste in a hierarchical social structure they do not have any right the writings of bama and kamble have the commonality of heart wrenching episodes of sufferings and miseries faced by dalit women the conditions of dalit women in their works clearly highlight the fact that the oppression and exploitation of dalit women has crossed the border of time baby kamble has highlighted how the mahar women would address the shopkeeper appasab would you please give this despicable mahar woman some shikakai for one paisa or while walking on the road if they come across any upper caste man or even a child they had to say the humble mahar woman fall at your feet master kamble argues that the centuries of oppression and slavery have left dalits especially dalit women in a very despicable state the hegemonic social structure of indian society has forced them to crush their sense of self they are left without any voice of their own these chants drive them to recognise their enslavement and subordination to the social hierarchy sangati gives us a glimpse into the world of dalit women who experience both caste and gender prejudice besides giving us an insight into the world of dalit women and the marginal position they occupy at the intersection of gender and caste these women are constantly exposed to the abuses and harassment bama has exposed the inhuman treatment meted out to dalit women through the detailed account of mariamma despite being a victim and falsely accused by uppercaste man mariamma is humiliated and is forced to pay a fine of rupees two hundred as gender and caste politics blamed her as the perpetrator it led her to become a victim despite being aware of the fact that mariamma has been falsely accused the members of her community dont have the courage to go and confront uppercaste people suppose these fellows go and question uppercaste men what if those rich men start a fight saying how dare these paraiyar be so insolent can we bring them to justice though after all we have to go crawling to them tomorrow and beg for work gender inequality and dominance of the uppercaste people in their daily lives have left these women without any security the social structure of their world is constructed in such a way that even in their daytoday life they are considered as an inert object to be appropriated without any scope for protest or representation in the decisions affecting them the dependence of the lower caste people on the upper caste landlords for their daily wages has even crippled their sense of duty and justice the texts explore the complex interplay between the marginalisation experienced by dalit women the overlapping forms of caste and gender discrimination and their active role in challenging these inequities bama and kamble utilise their literary works to illuminate the persistent and complex obstacles faced by dalit women through the act of recollecting instances of tyranny and humiliation the intention is to emphasise that dalit women do not passively endure abuse but rather actively establish their identities by embracing their unique personality the act of narrating and disseminating their personal experiences functions as a mode of resistance the objective is to enhance individuals capacity to critically analyse dominant narratives that perpetuate their marginalisation dalit women encounter a complex interplay of caste and genderbased marginalisation resulting in a multilayered framework of discrimination that originates from their simultaneous identification as dalits and as women the convergence of their distinct personal identities gives rise to a distinct manifestation of oppression that is frequently disregarded or undervalued the occurrence of social marginalisation encountered by individuals categorised as subhuman can be attributed to well entrenched social structures wherein their marginalised position is further exacerbated by the intersectionality of caste and gender the diverse nature of prejudice becomes apparent through its several expressions encompassing economic adversity social marginalisation restricted educational and healthcare opportunities and occurrences of both bodily and psychological detriment the book provides a thorough examination of the interconnectedness of these oppressive establishments presenting incisive perspectives on their contribution to the ongoing marginalisation of individuals the decision made by bama and baby kamble to document their own experiences has a dual function the utilisation of this specific approach is crucial in the endeavour to reclaim agency for dalit womens accounts from the prevailing discourse which frequently depicts them as passive entities vulnerable to victimisation through the open sharing of personal stories of oppression and degradation these individuals are actively contesting the prevailing discourse that aims to marginalise their perspectives and lived experiences the written work of the author acts as a concrete manifestation of their core thesis of individual agency emphasising the profound influence of historical circumstances on human empowerment moreover the narratives of dalit women emphasise the exceptional resilience and steadfast determination demonstrated by these individuals throughout difficult situations by engaging in the process of narrating the injustices they have encountered individuals underscore the intrinsic significance of recognition and communal assistance within the wider society structure the act of writing functions as a means to cultivate empathy and understanding while also serving as a platform for promoting dialogue on the interplay between caste and genderbased discrimination in the novel sangati bama emphasises the need for selfinitiated transformation stating i f we ourselves do not change our condition then who will come and change it for us the emphasis placed by bama on affirmative action highlights the significance of dalit women assuming agency in effecting transformative changes in their own conditions this statement reflects the notion that the occurrence of exterior change is contingent upon an individuals interior dedication to undergoing transformation marginality and marginalisation within the dalit community when we think about marginality the word conjures up images of margin however when discussed into sociological sense it shifts from location to people margin constructed around the idea of centre stands as the other of centre david d laitin defines it as thoroughly demeaning for economic wellbeing for human dignity as well as for physical security it conjures within itself the exclusion and deprivation faced by the others a thorough and indepth study clearly highlights how dalit women are ousted by dalit men despite being occluded by dalit men dalit women are marginalised within their community as well the works of bama and kamble highlight the extensive marginalisation that dalit women endure from the earliest stages of their lives bama places significant stress on the manifestation of marginalisation at infancy highlighting the early recognition of differential treatment between boys and girls the differential reaction to the vocalisations of infant males swiftly addressed through the provision of sustenance in contrast to the comparatively inadequate attention given to females establishes the foundation for enduring inequality throughout their lives during the early stages of adolescence girls are introduced to distinct societal expectations and assigned gender roles that differ from those allocated to boys the mandated exercises and games perpetuate old gender norms by assigning girls to domestic responsibilities while boys are encouraged to participate in physical activities moreover the practise of excluding women from active involvement in festivals serves to reinforce the subordinate status of women as it involves men assuming female duties the aforementioned account of initial encounters serves as a testament to the entrenched nature of marginalisation experienced by dalit women kamble also underscores the deeply ingrained character of social marginalisation experienced by dalit women the author adopts a devastating metaphor to depict her mothers state of confinement as comparable to that of a bird in a cage so symbolising the lack of personal liberty and autonomy the current state of confinement imposes limitations on the mothers ability to move freely so reinforcing the ongoing cycle of oppression inside the domestic realm these testimonies provide insight into the deep feelings of oppression and distress that dalit women endure within their familial and communal contexts the individuals displays of distress arise as a direct reaction to the painful recognition of being marginalised by their own relatives prompting them to convey these sentiments through their written works the economic vulnerability and restricted access to resources faced by dalit women exacerbate their suffering despite their active participation as valuable members of their communities engaging in daily wage labour alongside males women nonetheless experience marginalisation even from their male counterparts the lack of fair acknowledgement and decisionmaking power highlights a significant genderrelated disparity in their respective groups the economic involvement of individuals does not function as a means of achieving equality but rather serves to underscore the interconnectedness of their marginalised status wherein caste and gender cross to sustain exclusionary practises the reinterpretation of dalit womens marginalisation by bama and kamble is grounded in their intricate research that interconnects the dynamics of caste and gender by establishing a connection between these two dimensions they present a novel viewpoint on the lived realities of dalit women the utilisation of an intersectional approach by the authors reveals the intricate and complex character of marginalisation shedding light on its pervasive influence across different dimensions of the life of dalit women this recontextualisation enhances our comprehension of the intricate dynamics between societal frameworks and individual identities revealing the systemic nature of the obstacles they present and fostering a revitalised dedication to confronting and altering these deeply entrenched disparities the unending chain of oppression dalits are disadvantaged as they do not receive the dignity of their existence in the eyes of uppercaste people but dalit women are even worse off because they are viewed as objects by dalit males as well as by uppercaste people the social history of dalit lives clearly marks the dehumanised treatment of dalit women on account of them being both women and dalit the present texts illustrate the marginality faced by dalit women and the violence poverty and ignorance that characterise their subjugation bama in sangati has rightfully summarised it thus the position of women is both pitiful and humiliating in the fields they have to escape from uppercaste mens molestations at church they must lick the priests shoes and be his slaves while he threatens them with tales of god heaven and hell even when they go to their own homes before they had a chance to cook some kanji or lie down or rest a little they have to submit themselves to their husbands torment this depiction shows the susceptibility and lack of agency that women encounter even when endeavouring to participate in work and generate income shifting focus to the domain of religion bama elucidates the repressive dynamics experienced by women inside church environments the individuals are anticipated to demonstrate subservience through the use of metaphorical representations that symbolise unwavering compliance and submission the aforementioned manipulation highlights the utilisation of religious beliefs to sustain the oppression of individuals depending on their gender bamas statement succinctly captures the complex obstacles that women in their society encounter the essay elucidates the susceptibility of women in many professional domains their subordinate position within religious contexts and the persistent anguish experienced inside their domestic spheres similarly kamble has also talked about the misery and violence that dalit women face stating the life of the women in the lower caste was thus shaped by the fire of the calamities… just as the chaturavarna system created castes and sanctioned discriminatory practices the cunning creator of the world established the practice of making women dependent on men kamble underscores the interconnection of oppressive systems by drawing a parallel between the influence of the chaturvarna system and the subjection of women based on gender the plight experienced by dalit women exacerbated by the intersectionality of their caste and gender results in a dual state of marginalisation that renders them particularly susceptible to increased levels of vulnerability kambles statement highlights the complex and pervasive nature of discrimination illustrating its impact on various dimensions of the life of dalit women the manner in which she depicts the subject matter demonstrates a profound comprehension of the intricate relationship between societal frameworks conventional gender expectations and the complexities of power dynamics this particular viewpoint functions as a potent analysis of the underlying inequities that are deeply embedded into the structure of society the texts also recount the violent treatment meted out to these women by the male members of their family namely father brothers and husbands the acute display of violence is shown by these writers bama writes of how women are beaten by their husbands on slight or no pretexts at all i reared a parrot and then handed it over to be mauled by a cat your periappan actually beat her to death my womb which gave birth to her is still on fire he killed her so outrageously the bastard in another episode she recounted how a dalit woman named thayyi was beaten mercilessly by her husband stating i could hear thayyi weeping as i came closer and saw what was going on my eyes filled with tears thayyis husband was beating her up again and again with the belt from his waist she didnt even have a chattai on everywhere the strap fell on her light skin there were bright red weals nondalit feminists assumptions that dalit women can stand and fight against domestic violence are refuted by dalit womens accounts sangati and the prison we broke portray this ugly side of dalit society how men from these communities exploit their women the exploitation that the lower caste people face at the hands of the upper caste of people is further extended from lower caste men to their women the interlinked chain of oppressions has crippled the existence of dalit women having a life worse than the animal these writers have highlighted the targeted violence of the dalit women dalit men and their twisted patriarchy have become the beacons of brutality against their families the outsiderwithin and their standpoint dalit womens works should be viewed as a social discourse and reflection on their life experience in a historical context rather than as a simple personal narrative that chronicles the trajectory of their development these stories also demonstrate their vivacity and determination to recover stemmed from their sufferings is their zeal to survive and their motivation to persevere bama asserts that our women have an abundant will to survive however they might have to struggle for their last breath they somehow or other manage to find ways to cope with their pains and sufferings at times with patience and other times by resorting to coping mechanisms bama talked about the incident that she witnessed between pakkiaraj and his wife raakkamma to avoid the thrashing from her husband raakkamma started cursing him ayyayyo hes killing me vile man youll die youll be carried out as a corpse you lowlife you bastard the narratives provide evidence of the coping strategies employed by dalit women in response to their experiences of adversity the demonstration of agency among these women is evident in raakkammas verbal pushback against her husbands abusive behaviour as they engage in acts of defiance and strategic resistance these accounts offer insights into the many strategies employed by individuals to negotiate their circumstances demonstrating both patience and a willingness to challenge established conventions the depiction of these episodes by bama highlights the diverse tactics employed by dalit women in order to manage the obstacles they face thereby providing a comprehensive understanding of their acts of resistance the literary works produced by dalit women hold a broader significance that surpasses personal narratives they serve as complex societal narratives that reflect their lived experiences within a historical context rather than presenting a simple narrative of personal development these narratives contain the complex interplay of caste gender and historical factors that have shaped their experiences the accounts demonstrate a profound embodiment of vitality and determination exemplifying the enduring fortitude and resilience that emerge from their adversities bama asserts that dalit women demonstrate a steadfast resolve to persevere especially when confronted with challenges hence emphasising their unwavering fortitude that propels them forward despite difficult conditions analysing these narratives from the perspective of dalit women yields an epistemic advantage situated inside the societal hierarchys lowest echelon these individuals possess a keen comprehension of the mechanisms governing society and the inherent power dynamics embedded within it the complex network of power dynamics which are frequently concealed within establishments is revealed by examining the framework of caste classifications the literary contributions of dalit women are crucial in elucidating the latent political dynamics that influence their existence and revealing the entrenched power dynamics that maintain their marginalised status the marginalised position of dalit women highlights a deep understanding of indias stratified social system the aforementioned framework imposes many forms of oppression repression and marginalisation upon dalit women the individuals distinctive viewpoint honed through personal encounters offers a particular standpoint from which to grasp the complex nature of social interactions this particular viewpoint allows individuals to uncover the concealed mechanisms that uphold systems of castebased discrimination and gender bias at the core of their narratives lies the exploration of systematic oppression a phenomenon that grants individuals the ability to question and contest the dominant social structure these narratives function as a medium through which individuals express their opposition to the repressive societal standards that contribute to their subordination the narratives not only provide a platform for individuals who are marginalised by the prevailing political and social limitations but also offer insights into the intricate dynamics of those who actively perpetuate oppression within the same societal framework through this action these written works create an opportunity for an extensive examination of social ecology the literary compositions produced by dalit women extend beyond individual accounts functioning as potent social commentaries that mirror historical circumstances thereby articulating a distinct perspective these accounts exemplify the vibrancy and resilience that stem from the individuals experiences of hardship through the adoption of an ideology rooted in their individual experiences individuals are able to understand the complex and nuanced power dynamics that exist within a society structured around a caste system the tales presented by the individuals in question serve as a medium through which resistance against systemic oppression is expressed while also offering significant perspectives on the intricate dynamics between those who perpetrate oppression and those who are subjected to it conclusion within the societal framework marked by castebased hierarchies as observed in india dalit women experience a multitude of discriminatory practices that emanate from their dual identity as both women and members of the dalit caste this study explores the concept of dalit women as the outsider within through a comprehensive analysis of two literary works namely bamas sangati and baby kambles the prison we broke dalit women who occupy the lowest position in the caste hierarchy encounter a notable dearth of autonomy in their existence facing the combined weight of discrimination based on caste and the supremacy of patriarchal structures the concept of twofold marginalisation exposes individuals to heightened vulnerability hence exacerbating their difficulties in achieving empowerment and recognition dalit women exhibit notable fortitude and resolve in confronting severe obstacles despite their marginalised social status the portrayal of their unwavering resolve in battling repressive entities highlights their capacity for selfgovernance and ability to endure dalit women by virtue of their marginalised position have a unique standpoint that empowers them to recognise and challenge dominant power structures with a heightened understanding of the linked manifestations of oppression they encounter this particular viewpoint offers a significant agency for conceptualising a society that is characterised by more fairness in which the perspectives of the most disadvantaged individuals are recognised and given appropriate consideration to cultivate a societal environment characterised by inclusivity and equity it is crucial for policymakers activists and communities to actively participate in cooperative initiatives the first stage in addressing the systemic obstacles that contribute to the continued oppression of dalit women entails recognising the existence of intersectional discrimination they face the opportunity for empowering dalit women to break out from cycles of marginalisation and poverty lies in the availability of highquality education and economic possibilities in addition the incorporation of marginalised individuals in decisionmaking processes can successfully enhance their voices and effectively advocate for their rights and needs bama and baby kamble present a powerful testimony that advocates for the acknowledgment and appreciation of the agency and perseverance demonstrated by dalit women these writings also underscore the significance of collaborative endeavours in eliminating the widespread disparities deeply ingrained in both caste and gender the attainment of a societal framework that upholds the principles of dignity respect and equality for all individuals regardless of their caste or gender necessitates collective efforts

owing to the graded inequality inherent in indian society dalit women lie at the bottom of the hierarchy with no power to execute in short one can say that they are dalit of dalits the present paper looks at the challenges and exclusionary practices faced by the dalit women with reference to the works of bamas sangati 2005 and baby kambles the prison we broke 2008 delving into the concepts of gender and caste the paper aims to demonstrate how both writers portray the idea of the outsider within the identity of dalit women it will also deal with how this outsider within identity gives them a standpoint of their own in its entirety the paper highlights the challenges and haplessness of dalit women because of their identity and their zealousness in fighting the oppressive forces

requirements based on food preferences availabilities and dietary patterns in arabicspeaking countries the prevalence rates of chronic diseases and obesityrelated comorbidities have increased in relation to the decline of healthy dietary habits in these countries concurrently this region is also experiencing a growing burden of undernutrition and a dietary shift towards a westernized diet characterized by convenience foods high in sodium saturated fats and refined sugars recent studies continue to propose the need for culturally congruent dietary patterns and healthy lifestyles in this region to address these public health challenges successful dietary intervention and education of individuals from arabicspeaking countries begin with cultural sensitivity to promote proper dietary intake for this group healthcare professionals must understand and respect clients food practices ethnic heritage and lifestyle clinicians and registered dietitians are responsible to communicate materials and education in an effective manner that emphasizes the ethnicity of individuals such as immigrants from arabicspeaking countries representative foods for each food group should be determined based on cultural foods that clients are accustomed to consuming and serving sizes should be based on predetermined amounts which improve health outcomes graphical representation of culturally appropriate food choices and servings sizes is a useful education tool for clinicians and registered dietitians these graphics can provide guidelines to improve dietary intake for the individual while allowing the educator to maintain sensitivity to the cultural food practices of the individual furthermore not only are dietary graphics culturally sensitive but they are also an effective means of improving health communication therefore developing and promoting graphical representations of regional food guidelines for arabicspeaking countries can help recipients maintain and understand culturally congruent dietary intake while previously published reviews offered an introduction to international food guidelines no review has been published to provide a focused examination of culturally congruent food guidelines in the arabicspeaking region the purpose of the present work is to provide dietitians public health educators and health professionals a narrative review of proposed food guidelines from various arabicspeaking countries the current review offers a congruent and illustrated understanding of international food guidelines and improves cultural competency and awareness among health professionals operating in this region as it relates to public health nutrition in countries hosting significant target populations originating from arabicspeaking countries for the purpose of the review the arabicspeaking countries were defined by the twentytwo member countries of the league of arab states the guidelines were identified and selected through the faos near east region for foodbased dietary guidelines the who regional office for the eastern mediterranean country profiles and the ministries of health from member countries of the league of arab states promoting a healthy diet for the who eastern mediterranean region userfriendly guide in 2004 in response to public health concerns regarding the high prevalence of malnutrition in addition to increases in overweight obesity and resultant dietrelated chronic diseases such as cvd type 2 diabetes hypertension and some cancers the who authored a recommendation for a regional strategy on nutrition through a consultative process in collaboration with member states of the eastern mediterranean region promoting a healthy diet for the who eastern mediterranean region userfriendly guide was developed to provide evidencebased and culturally congruent dietary recommendations for populations living in the member states of the eastern mediterranean region aimed at reducing the risk of obesityrelated comorbidities and undernutrition the guidelines suggested in the publication offer foodbased dietary guidance while accounting for the availability of widely consumed local and affordable foods and regional and cultural food practices foodbased dietary guidelines provide the consumer with an easytounderstand framework for healthy eating by encouraging dietary patterns confirmed through clinical and epidemiological research that are associated with a reduced rate of dietrelated diseases these evidencebased guidelines encourage maintenance of a healthy body weight for the people of the eastern mediterranean region through consumption of whole grains fruits vegetables lean meat and poultry and lowfat dairy and by suggesting that a variety of healthful foods are chosen each day if possible consumption of fish is encouraged at least twice weekly limits on added sugars salt and fats and oils are advised while the importance of consuming dietary fat from unsaturated fat sources and n3 fatty acids from foods such as nuts flaxseed and fish is emphasized each guideline clearly associates the potential health benefits and negative disease outcomes that food categories may be related to such as increased intake of fruits and vegetables is associated with lower risk of type 2 diabetes stroke cvd macular degeneration and several types of cancer and is accompanied by suggestions to increase or decrease the food being discussed and key recommendations for the respective food group consuming recommended amounts of clean water and practising food safety in handling and preparation of food are emphasized the who emro dietary guide also offers a corresponding visual representation of the recommendations similar to the us department of agricultures myplate and dietary guidelines for americans public health england has noted that globally countries depict the complexities of dietary reference values and foodbased recommendations using a simplified graphic to complement national dietary guidelines based on recommendations of the who and the fao countries should develop simple dietary guidelines that address specific national public health concerns and which are relevant to people of different ages lifestyles and cultures in the region in developing such guidance the shape layout and design of a corresponding graphic are often used to impart the relationship of regional and local practices customs and beliefs to the dietary recommendations such graphical representations for dietary guidance are an important tool for nutrition educators dietitians and public health practitioners who work with diverse populations across the lifespan to promote health and reduce dietrelated disease incidence as a visual tool graphical arab gulf states saudi arabia lebanon qatar who regional office for the eastern mediterranean oman fig 1 foodbased dietary guidelines from arabicspeaking countries dietary guidelines of the arab world representations of dietary guidance provide a quick and easy way to convey information that generalizes the dietary recommendations of a nation and may be a practical way to discuss dietary behaviours in the country of origin and with immigrant populations seeking dietary and health information because the who eastern mediterranean region is comprised of several predominantly arabicspeaking nations that exhibit distinct cultural and subcultural beliefs various graphic representations of dietary guidance have also been developed these graphics may be used in the region for which they are developed or as a tool to develop rapport and understanding of unique issues and opportunities for public health educators to assist their immigrant or firstgeneration clients the arab food dome when the arab food dome was first contemplated in 2012 there was no specific dietary guidance for native populations residing in the arab gulf states while the need for the establishment of dietary guidelines for arab populations was identified it was not until the who emro published promoting a healthy diet for the who eastern mediterranean region userfriendly table 1 recommended food group quantities and physical activity from selected food guidelines in the arabicspeaking region promoting a healthy diet for the who eastern mediterranean region userfriendly guide arab food dome the healthy food palm lebanese dietary guidelines qatar dietary guidelines omani guide to healthy eating grains guide shortly after musaiger et al noted the lack of dietary guidance that the eastern mediterranean region was provided with dietary guidelines specific to the geographic region the appearance of the food dome invokes the domes commonly observed in the architecture of the region domes are found in the home and on mosques churches and other cultural institutions the food dome shaped as its name suggests depicts the food groups vertically to explain that all foods are equal from their nutritional point of view and the only difference is in the amount of food that should be eaten from each group while the base of the dome is filled with graphic representations of people engaged in physical activity to illustrate the importance of incorporating such activities daily research suggests that one of the primary factors contributing to the increase in overweight and obesity in the region and the related rise in dietrelated disease is the decline in physical activity and a regional dietary transition towards westernized diets thus the arab food dome emphasizes the importance of adults attaining at least 30 min of exercise most days of the week while encouraging children to engage in a minimum of 90 min of physical activity daily in general the food dome reflects the recommendations of promoting a healthy diet for the who eastern mediterranean region userfriendly guide while adhering to regional and cultural food practices and access dietary guidelines for saudisthe healthy food palm like the arab food dome the healthy food palm was created in 2012 as a graphic representation of the ideal patterns of food consumption demonstrated as a pictorial representation of the recommended servings from each food group the indicator of suggested total servings per food group is demonstrated by the relative size allotted to each food group within the palm tree graphic as well as noted in the trunk of the palm tree similar to the us department of agricultures myplate graphic which visually demonstrates the proportions of food groups by demarcating them on a table setting graphic the healthy food palm visually indicates that the foundation of a healthful diet depicted in varying sizes of palm fronds should be comprised of bread and cereals especially whole grains fruits and vegetables followed by smaller amounts of milk and dairy products and meat and legumes with the smallest palm fronds indicating that oils and sugars should be used sparingly additionally the healthy food palm is shown growing from the ground the base indicating the need for 3060 min of physical activity daily inadequate physical activity has been noted as a concern in adolescents in saudi arabia encouraging daily activity as the foundation of a healthy lifestyle is a theme emphasized in promoting a healthy diet for the who eastern mediterranean region userfriendly guide as well as the food guidance graphics being developed throughout the region interestingly creation of the healthy food palm was based on a review and analysis of sciencebased dietary guidelines such as the dietary guidelines for americans and those in the uk and canada rather than the who emros userfriendly guide the development process included a review of dietary patterns in saudi arabia a review of dietrelated diseases common to saudi arabia a review of existing guidelines and the development of a graphic that would appropriately depict the recommendations in a meaningful and relevant way the choice of the palm as the outline for the graphic is based on the trees cultural and economic significance in the region the palm appears on the flag of saudi arabia and is considered to represent vitality growth and prosperity the pictures of food within the graphic capture regionally identifiable and commonly used products such as a variety of breads including flat and yeast breads and baklava pictured in the sweets category the foodbased dietary guideline manual for promoting healthy eating in the lebanese adult population to support the national nutrition strategy for lebanon the faculty of agricultural and food sciences of the american university of beirut collaborated with the lebanese national council for scientific research and published fourteen guidelines related to healthy eating and lifestyle practices in 2013 the foodbased dietary guideline manual for promoting healthy eating in the lebanese adult population the guidelines promote behaviours to reduce the prevalence of chronic noncommunicable diseases such as obesity cvd type 2 diabetes and cancer and also address inadequate food intake and micronutrient deficiencyrelated diseases the intention is for these to be used in all settings including hospitals private clinics homes and universities as well as in healthrelated businesses although the guidelines are termed foodbased they target a set of behaviours that are meant to be implemented as a whole the goal is to improve the health of lebanese adults through behaviour change and reduction of chronic diseases socioeconomic disparities contribute to rising rates of obesity and lower rates of physical activity in the population in addition to dietary intake quality the guidelines target overall behaviours and outcomes as well as specific dietary recommendations and hydration as in many developing countries the nutrition transition in lebanon has been characterized by the dual burden of undernutrition and rising rates of obesity among all ages comorbidities related to obesity have been attributed to increasing westernized diets and lifestyle behaviours among older lebanese adults living in the community a western diet pattern has been associated with lower indices of healthy eating patterns the traditional lebanese dietary pattern a version of the mediterraneanstyle diet appears to be protective against metabolic syndrome in a crosssectional survey of dietary patterns in lebanese adults conducted in 20082009 a fast food dessertbased pattern was associated with a higher likelihood of metabolic syndrome hypertension and hyperglycaemia when compared with the traditional lebanese dietary pattern a similar association between the western diet pattern and overweight was found among lebanese adolescents in the same survey studies in other groups have confirmed consistent relationships with the negative effect of a dietary pattern emphasizing westernized processed foods as well as risk factors for this pattern among different ages and socioeconomic groups in lebanon while these patterns have been defined by consumption of foods within food groups the overall pattern is the predominating theme associated with risk rather than specific food groups although the lebanese guidelines specifically target the adult population a need exists for greater attention to dietary guidelines in the paediatric population as well a study of orphaned children in tripoli showed a high prevalence of sedentary behaviour and inadequate intakes of vegetables fruits and proteins as well as high intakes of sweet and salty snacks compared with the american dietary guidelines promotion of the traditional lebanese dietary pattern and the messages of the lebanese cedar food guide could help to inform policy for the most vulnerable children the omani guide to healthy eating the department of nutrition in the ministry of health in oman developed the 2009 omani guide to healthy eating in response to the whos global strategy on diet physical activity and health the guideline includes ten messages tailored for use as a reference for training materials counselling and education the target audience for the guide includes teachers of all levels community educators and health professionals the guide is designed around a circular graphic illustration in the form of a plate highlighting each food group in proportions consistent with the ten messages to support healthy eating in oman the intended use is to promote adequate nutrition for the general population over 2 years of age with a focus on dietary selections to reduce the prevalence of obesity and chronic diseases the guidelines include recommended nutrient intakes by age group and individual nutrients the omani guide is nutrientfocused and provides specific serving sizes for all age groups over 2 years with the intent of achieving targeted nutrient recommendations the selected food groups are more granular than in some other guidelines with recommended daily amounts specified for the following food groups whole and refined grains fruits vegetables meats and alternatives legumes milkdairy and fats a diet lower in total and saturated fat is recommended a substantial section of the omani guidelines is devoted to detailed recommendations for safe food and water that include five steps that promote safe foods and avoid contamination due to microorganisms andor toxins in addition to food choices the omani guide to healthy eating includes recommendations for physical activity including aerobic and musclestrengthening activities these are consistent with the more recent acknowledgment of the need for a national strategy to address modifiable risk factors for the rising burden of dietrelated diseases in oman descriptive data from the oman world health survey in 2008 suggest a rising prevalence of metabolic syndrome with opportunities to address behaviours that mitigate risk as well as the need to promote quality patient care at all healthcare system levels among a group of omani adolescents high prevalence rates of sedentary behaviour low level of physical activity and highenergy food consumption were observed although prevalence of overweight and obesity was not especially high in this group increasing prevalence of obesity among older adults with moderate energy intakes suggests low levels of physical activity may be an important factor sleep hours were lower than recommended in adolescents and may be a behaviour of interest for future guides due to the association of sleep deprivation with overweight and obesity a more recent study of adolescents showed a rising prevalence of overweight and obesity and a positive association of consumption of fast foods sweets and cakes with overweight or obesity these findings are consistent with the rapid transition to a westernized diet in this population and its associated effect on health and nutrition behaviours the qatar dietary guidelines in 2015 qatars supreme council of health health promotion and noncommunicable diseases public health department published foodbased dietary guidelines for the state of qatar the guidelines include eight recommendations developed to direct individual behaviour change and policy creation and evaluation eat healthy choices from six food groups maintain a healthy weight limit sugar salt and fat be physically active drink plenty of water adopt safe and clean food preparation methods eat healthily while protecting the environment and take care of the family adding a plantbased environmentally friendly component to a statesponsored dietary standard is relatively unique to the state of qatar the guidelines are depicted using an open clam shell with illustrations of six food groups portioned inside vegetables fruit cereals and starchy vegetables legumes milk dairy products and dairy alternatives and fish poultry meat and meat alternatives adopting behaviours and policies aligned with the qatar dietary guidelines will reduce risk factors associated with chronic noncommunicable diseases cancer diabetes cvd and stroke dietary behaviours in qatari communities fall short of who guidelines for recommended daily allowances in a crosssectional study the authors found younger adults in qatar consumed fewer than two servings of fruits and vegetables daily and an equal number of meals prepared at home and fastfood meals per week coupled with mean bmi and rate of overweightobesity qatari men rank among the statistical mean when compared with arabicspeaking countries yet obesity rank is 41 higher for qatari women compared with men although the world bank classifies qatar as a high income country and the who reports high access to health services and significantly higher per capita total expenditures on health adult risk factors for qatari adults including dietrelated chronic diseases such as high blood pressure obesity diabetes and cvd risk are increasing in response to dietrelated risks for noncommunicable disease qatars supreme council of health developed a national dietary guideline task force comprised of a coalition that included medical associations academic institutions research centres and the national food security program the task force used evidencebased processes that followed international best practices and regional reports to develop the qatar dietary guidelines in 2015 the graphic illustration of the qatar dietary guideline includes a large open clam shell that reveals an inner plate divided into six unequal sections from cereals and grains down to fish poultry meat and eggs representing each groups contribution to a healthy diet hovering above the clams plate is a large drop of water signifying its importance to the guideline the guideline also includes behaviours related to a healthy diet including physical activity respect for the environment clean and safe food preparation methods and taking care of the family the qatar dietary guidelines are intended to provide overarching support in a topdown approach to community and individual health where policy leads to behaviour change as an example the graphical representation allows the qatari supreme council of health to express recommendations for types and amounts of food across age education and cultural barriers more effectively than objective mathsbased formulations however communicating the information in a culturally sensitive and easytounderstand method will not lead to sustained behaviour change or behaviour maintenance guidelines that suggest andor promote communitylevel interventions are more effective in supporting the original messages and fostering sustainability examples from the qatar dietary guidelines include calls for educational programme outcomes such as physical activity increase selfreflection on dietary behaviours food label literacy decreased sitting time understanding environmental factors associated with dietary behaviours and realizing the negative consequences associated with not following the guideline conclusions the present narrative review of current food guidelines within the arabicspeaking region should provide cultural context for health education health promotion and nutrition professionals within the region and for those looking to compare or understand crosscultural policies all guidelines presented in the review are comparable to the mediterraneanstyle diet outlined by the who emro which provides consistency across the region these similarities were observed in dietary recommendations that focus on a predominant consumption of whole grains fruits and vegetables and healthy plantbased oils with reduced consumption of red meats animalbased proteins dairy products animal fats and added sugars dietary guidelines in the arabicspeaking region have seen a shift towards including nontraditional food recommendations physical activity food preparation maternal health and environmental health are all examples of new language to support a healthy diet practitioners should access these supplementary guidelines when developing and promoting behaviour change associated with dietrelated risk factors additionally in the light of the current political and humanitarian crisis observed in arabicspeaking countries such as yemen syria the palestinian territories etc and the consequent forced displacement of these respective populations these guidelines could serve as an influential resource of health promotion for public health practitioners operating in displaced arabicspeaking communities around the world programme evaluation efforts should also consider the culturally compatible guidelines outlined in the present paper when determining the effectiveness of existing programmes using specific guidelines when working with individuals adds validity to a programmes perceived value and provides a potential universally recognized symbol for a healthy diet however those guidelines should be recognizable by and acceptable to the target audiencesculturally visually and affectively although a universal dietary guideline is a discussion subject in the literature the approach potentially eschews the inherent benefits of culture specificity tailoring dietary guidelines and their applications to a specific culture region or ethnic identity could increase recognition acceptance and use by their target audience collaboration and capacity building between communityand clientlevel practitioners and government agencies that develop and sponsor dietary guidelines should be encouraged and bidirectional health education health promotion and nutrition practitioners should contribute to the research cycle by providing process impact and outcome evaluation data on the usability and effect of dietary guidelines on behaviour change graphical depictions of dietary guidelines that include cultural ties represent a primary connection between the author practitioner and target audience in completing the research and evaluation cycle government agencies should incorporate data collected in the field during regular reevaluation of dietary guidelines

objective dietary guidelines for food groups types and portion sizes are common practice at the national level as the relationship between nutrition and disease and the influence of cultural identity on individual behaviour become clearer dietary guidelines necessarily evolve today the arabicspeaking region is experiencing a dual burden of undernutrition and increasing rates of overweight and obesity cultural congruency among dietary guidelines in the arabicspeaking region and how they affect health education health promotion and nutrition programme planning or individual dietary behaviours have yet to be examined the present work provides dietitians and public health professionals a narrative review of proposed food guidelines for the arabicspeaking region design the current review examined five established dietary guidelines within the arabicspeaking region namely the arab food dome arab gulf states the healthy food palm saudi arabia the lebanese dietary guidelines the omani guide to healthy eating and the qatar dietary guidelines and compared findings with the regional eastern mediterranean guidelines developed by the who individual guideline recommendations are tabled for comparative review setting the arabicspeaking region participants respective arabicspeaking populations results health educators community health practitioners and nutrition professionals can benefit from the cultural contexts associated with dietary guidelines in this region conclusions communitylevel policy and individual behaviour change will benefit from cultural sensitivity health communication and behaviour change programming require cultural competence provided in the present review and programme evaluation efforts prior to and after implementation should include a detailed understanding of how culture shapes regional policy and individual nutrition behavioursestablished dietary food guidelines serve to help individuals meet dietary recommendations to improve health and decrease risks for chronic disease andor nutrition deficiency 1 in the usa the dietary guidelines for americans were developed in response to increases in relationships between nutrition and disease established food guides and dietary recommendations to improve population health exist internationally international food guidelines are based on cultural preferences food availability and scientific evidence painter et al 2 reviewed food guides and illustrations for australia canada china germany korea mexico the philippines portugal sweden and the uk these guidelines serve as culturally congruent dietary definitions and recommendations to assist individuals in meeting their daily dietary

introduction c igarette smoking is common among youth especially in central and eastern europe 1 the global adult tobacco survey in romania reveals that the highest proportion of initiation of daily smoking among the general population occurs during adolescence with 43 of adult smokers starting between the ages of 1719 followed by 22 of daily smokers starting between ages 15 and 16 2 the tobacco atlas revealed high rates of daily tobacco use in central and eastern europe among boys and girls ages 1315 respectively bulgaria 244 and 316 ukraine 23 and 8 serbia 93 and 89 moldova 185 and 56 in moldova and hungary 33 and 28 1 in romania 471 of boys and 354 of girls have ever smoked cigarettes and 176 of boys and 95 of girls have smoked a cigarette in the past 30 days 3 smoking is more prevalent among boys in latvia lithuania and romania with the difference of 10 or more 4 adolescence is a period of increased risk for tobacco experimentation and children living in foster care homes are especially vulnerable to early initiation of smoking as a comorbid condition of more general emotional and behavioural problems 5 a study conducted in the uk found that as many as twothirds of children 1117 years olds living in residential care have tried smoking 6 and an estimated 9 of foster care children between 11 and 15 were regular smokers 7 children in traditional noncustodial families are at risk of smoking if their parents smoke and if they are exposed to second hand smoke in the home it is estimated that annually at least 23 000 young people in england and wales start smoking by the age of 15 as a result of exposure to second hand smoke in their home 8 in addition to parental influences real and perceived peer smoking is consistently associated with experimentation and current smoking behaviour among adolescence across cultures 9 10 11 in a multigenerational study of smoking risk at youths authors examined whether exposure to parental smoking and nicotine dependence predicted prospective smoking trajectories among adolescent offspring adolescents with parents who were nicotinedependent smokers at baseline were more likely to be early regular smokers odds ratio 118 95 confidence interval 105133 and early experimenters or 104 95 ci 104125 with each additional year of previous exposure to parental smoking parents who were nonnicotine addicted or who were former smokers were not associated with adolescent smoking trajectories 12 very few studies have investigated the correlates of experimentation and current smoking among foster care home children 13 14 15 and no such studies have been conducted in romania therefore it is essential to determine factors associated with smoking in this unique and vulnerable population in order to implement health education and health policies and that reinforce primary prevention 16 this is the first study to report the prevalence and correlates of tobacco use among underage residents in foster care homes of the child protection authority in romania methods sample data collection trained data collectors conducted inperson surveys with all children januarymarch 2014 in mures county and november 2014february 2015 in alba covasna and harghita counties after explaining the purpose of the study and receiving assent from the children measurement sociodemographic questions included age sex and time spent in the foster care home peer smoking was measured by asking how many of your five most important friends have ever tried cigarettes and how many of your five most important friends smoke at least one cigarette a week response options included none at least one two three four all responses were dichotomized for both questions as having at least one friend who had tried or who smokes at least one cigarette per week smoking habits and perceptions of foster families included whether their foster mother and foster father are current smokers natural sibling smoking status was coded yes if at least one sibling was reported to be a smoker children without natural siblings in the foster care home were coded as no parental reaction to respondent smoking was determined by the following how would your foster parents react if they caught you smoking respondents who reported that their parents would be angry or very angry were coded as 1 vs 0 for moderately angry or not angry parental reaction was coded separately for mothers and fathers tobacco use behaviour among respondents was measured by several questions the main outcomes included having ever experimented with tobacco even a single puff and current use defined as having smoked a whole cigarette in the past 30 days other smoking behaviours are included for descriptive purposes and included age at initiation which defined as having smoked an entire cigarette before age 10 between ages 11 and 14 and between ages 15 and 17 as well as whether the respondent had smoked 5 packs vs 5 or more packs in his or her lifetime analysis the analytical sample included 791 respondents 18 years of age living in romanian foster care homes who had complete data on tobacco use behaviour descriptive statistics on all categorical variables were computed and are reported as raw numbers and frequencies in table 1 to assess the association among sociodemographic peer and familial factors and tobacco use behaviours among foster care children we regressed all covariables on having ever experimented with smoking and current tobacco use using binary logistic regression analyses we report unadjusted and adjusted ors and 95 cis for ever having experimented and current tobacco use we also conducted multivariable logistic regression which simultaneously adjusted for all covariates in the analytical model all analyses were conducted using stataic version 140 results description of the sample the respondents were 507 girls and an average of 136 years thirty percent of respondents spent five or more years in the foster care home almost half of the respondents reported ever trying smoking and 259 are current smokers almost 1 in 10 children reported smoking a whole cigarette prior to age 10 among current smokers 215 reported daily smoking in the past month the majority of children reported that at least one of his or her most important friends had experimented with smoking or had smoked at least one cigarette in the past week about onethird of respondents reported that their foster mother and foster father are current smokers in addition children perceived that foster mothers and fathers would be angry or very angry if they believed the respondent was smoking factors associated with experimentation with smoking in logistic regression models factors associated with increased odds of smoking experimentation in the unadjusted bivariate model and adjusted multivariable model were similar being 1317 years old was associated with a 3fold increased odds of experimentation while having friends who are current smokers was associated with a 6fold increase in having ever tried smoking familial influence was also important in both unadjusted and adjusted models in the multivariable model foster father smoking was associated with a 2fold increase in experimentation while having siblings who smoke increased the odds 3fold parental influence was not related to tobacco experimentation in the multivariable model factors associated with current smoking in logistic regression models older children were more likely than younger children to be current smokers yet as time in foster care increased the odds of current smoking decreased children in the homes 15 years were about half as likely to report current smoking whereas having been in the home for more than 5 years was associated with an even lower odds of regular smoking controlling for age of the child having friends who smoke was associated with 4fold increased odds of smoking among the respondents having a foster mother or a sibling who smokes increased the odds of current smoking more than 2fold discussion the global youth tobacco survey data on the prevalence of cigarette consumption among students aged 1315 years in 25 tobacco use among children in rome european countries showed that 22 of boys and 18 of girls were current smokers 17 in addition data from the 2013 national youth tobacco survey reveal that 46 of us high school students have ever tried tobacco and 23 reported current use of any tobacco product however only 29 of middle school children represented in the nyts data report smokers 16 the 2004 and 2009 romanian gyts suggests a declining trend in ever smoking cigarettes and current cigarette smoking among a nationally representative sample of romanian adolescents in grades 68 18 although foster care children in this study have similar rates of ever smoking compared with the general population of adolescents in romania their current smoking is twice as high as the prevalence reported in the gyts although the ages of the two samples are not directly comparable the inclusion of younger children in our sample should mitigate at least some of the difference attributable to our inclusion of older children more than one in 10 children in romanian foster care homes reported smoking an entire cigarette at age 10 or younger and another 17 report having smoked the first cigarette between ages 11 and 14 in other words almost one in three children under the age of 15 reports having smoked an entire cigarette when compared with the general population however these data are promising according to the gyts 383 of ever smokers initiated smoking prior to the a children without biological siblings coded as 0 biological children in romanian foster care homes remain together whenever possible age of 10 years old we observed an interesting phenomenon among children living in romanian foster care home despite having higher rates of current tobacco use compared with the general population of romanian adolescents we find that the longer time spent in foster care the decreased likelihood of tobacco experimentation and current smoking controlling for age of the child therefore we may hypothesize that the foster care system is likely doing a good job of deterring tobacco use among children who enter the system at an early age a hypothesis that should be tested in longitudinal analyses like other studies close friendships with smoking peers was the most robust predictor of tobacco experimentation and current smoking 19 20 21 among romanian adolescents ages 1314 in the general population peer influence was the strongest predictor onset in multivariable analyses 22 in addition to the role of peer smokers influencing nonsmokers to start smoking lakon et al reported that there is an important role for nonsmoking peers to influence adherence to nonsmoking norms and encourage smokers to stop using tobacco 23 the foster care setting is an optimal venue to test this hypothesis as children in these settings share both home and school environments where social norms are promulgated and reinforced we also observed that foster parental behaviour was associated with the respondents smoking behaviour but in distinct ways foster father smoking behaviour was associated with increased odds of experimentation but not of current use conversely foster mother smoking behaviour was not associated with experimentation but was associated with current use sibling smoking behaviour was also associated with respondent smoking behaviour in both experimentation and current tobacco use these findings suggest that parental behaviour plays an independent and important role in the tobacco dependence trajectory and should be a focus of future interventions placement into custodial care is often a signal of lower socioeconomic status which has consistently been shown to predict tobacco experimentation and addiction 24 25 26 this is the first study to evaluate the prevalence and correlates of smoking behaviour among underage children in romanias foster care homes while robust in sample size and likely generalizable to other foster care homes in romanian there are some limitations first this is a crosssectional study therefore we can only estimate associations not causation second we focused only on romania which may limit the generalizability to romania or other eastern european countries despite these limitations results from this study demonstrate the high prevalence of tobacco use among children living in foster care homes of the government which is markedly absent in the scientific literature and suggests the need for tobacco prevention and cessation programmes targeting this vulnerable population conflicts of interest none declared key points residents living in foster care homes of the government are a unique and vulnerable population at risk for early initiation of smoking due to the number of very high rates for current use we confirm the importance of specifically tailored preventive programmes for this vulnerable young population primary prevention in terms of antitobacco education should be started as early as possible in the basic school programmes especially given that 1 in 10 children reported experimenting with tobacco under the age of 8 the contribution of smoking to mortality during working age at different levels of leisuretime physical activity tea lallukka 12 jouni lahti 1 eero lahelma 1 ossi rahkonen 1 1 department of public health university of helsinki helsinki finland 2 finnish institute of occupational health helsinki finland correspondence tea lallukka finnish institute of occupational health po box 40 fin00251 helsinki finland tel 358 43 825 4882 email background smoking and physical inactivity are linked to mortality but it is not known whether the association between smoking and mortality is affected by the amount and intensity of physical activity we examined the joint associations of smoking and physical activity with mortality while taking key covariates into account methods we linked survey data collected in 20002002 from among 4060yearold employees of the city of helsinki finland with complete register data on allcause mortality from statistics finland smoking leisuretime physical activity and covariates were measured at baseline we fitted cox regression models and the followup continued until the end of 2013 no gender interactions were found results a total of 228 deaths occurred during the followup smokers were at an increased risk of mortality after full adjustments but the risk was higher among inactive and moderately active smokers than among vigorously active nonsmokers the excess risk for vigorously active smokers or for inactive or moderately active nonsmokers could not be confirmed conclusion the highest mortality risk was found among physically inactive or moderately active smokers prevention of smoking and engaging in vigorous physical inactivity among smokers might prevent mortality during working age introduction s moking is a widely examined public health concern and physical inactivity has also emerged as a key contributor to global noncommunicable diseases and excess mortality 12 it has been estimated that 10 of premature mortality worldwide is attributable to smoking while the corresponding figure for physical inactivity is around 9 3 earlier metaanalyses further highlight the importance of vigorous physical activity in the prevention of mortality although the mortality risk among those partaking in

background children living in facilities under the supervision of child protection authorities are vulnerable to early smoking experimentation this is the first study to report the prevalence and correlates of smoking behaviour among foster care home residents in romania methods we conducted an inperson crosssectional survey of 914 resident children in 148 foster care homes of four transylvanian counties we included children 18 and those with complete tobacco use information in the analytical sample n 791 sociodemographic peer and foster family characteristics were evaluated for their influence on tobacco experimentation and past 30day use results respondents included 507 girls of average age 136 years range 817 almost half reported ever experimenting with tobacco 446 and approximately one in four reported past 30day use 259 factors significantly associated with an increased odds of smoking experimentation and past 30day use in the multivariable model included being 1317 years old vs 12 years having friends who are current smokers and having a sibling who smokes living in a home with a foster mother or foster father who smokes was associated with increased odds of experimentation and past30 day use respectively the longer time living in foster care was associated with decreased odds of experimentation and past 30day use controlling for all covariates conclusion antitobacco programmes that incorporate the role family and peers to reduce smoking are needed to address the high rates of use among romanian foster care children

background deprivation is defined as a state of observable and demonstrable disadvantage relative to the local community or the wider society or nation to which an individual family or group belongs 1 socioeconomic status refers to an individuals level of resource or prestige in relation to others and is traditionally measured through factors such as wealthincome place on a social hierarchy or class system and level of education or occupation 2 ses may be assessed at the individual or contextual level eg neighbourhood level 3 for the remainder of this work we will focus on the contextual level ses where low ses can be understood as indicative of material financial or social deprivation in a neighbourhood children rely on their parents ses such as the neighbourhood they live in and the financial status of the family they belong to 4 5 6 the effects of neighbourhood ses on babies and children have been studied in previous literature for instance when a pregnant woman lives in a deprived neighbourhood she has higher odds of adverse perinatal outcomes such as preterm birth a child born small for gestational age and stillbirth 7 moreover children living in deprivation are more likely to be overweight or obese during childhood and to have developmental delay when growing up 8 9 10 growing up in deprivation is related to higher odds of smoking and less physical activity in later life 11 the longer the exposure to deprivation during childhood the higher the odds of developmental delay and deviant behaviour in adolescence 89 for adolescents living in deprivation is associated with less physical activity and behavioural and psychosocial problems 5612 as young adults these children show weaker work commitment 13 in the past two decades it has been generally acknowledged that ses operates at multiple levels to affect wellbeing 14 15 16 17 contextual level ses measurements such as neighbourhood ses have been recognised to provide information about exposures to violence and hazards as well as access to recreational and institutional resources 14 for children there is evidence that neighbourhood of residence is associated with health school achievement and behavioural outcomes even when individual level income and education of the parent are controlled for 14 17 18 19 chetty et al showed that neighbourhoods in which children grow up shape their earnings college attendance rates and their fertility in later life 20 there is also evidence that living in a lowses neighbourhood may contribute to the development of behavioural problems and increase the likelihood of single parenthood and teenage motherhood 21 additionally teenage motherhood is often accompanied with poor educational achievement and unemployment of the mother 21 osofsky argued that children growing up in poor urban environments are frequently exposed to guns knives drugs and acts of random violence 22 exposure to such violence also interrupts a childs ability to solve problems 14 furthermore according to leventhal and brooksgunn the most consistent finding is that living in a highses neighbourhood has positive benefits for school readiness and school achievement 17 in the netherlands a western european developed country geographical differences in health outcomes between neighbourhoods are high 23 24 25 these differences may be attributed to neighbourhood ses 202326 additional to differences in health neighbourhood differences in child wellbeing could also be attributed to neighbourhood ses 27 28 29 to the best of our knowledge a study on neighbourhood ses and neighbourhood social indicators of child wellbeing has not been conducted before most studies only focused on child development instead of wellbeing and on the crosssectional association between ses and healthrelated outcomes while the exposure and the outcomes as well as their associations are not fixed over time 3031 therefore we aimed to investigate the association between neighbourhood deprivation based on ses and social indicators of child wellbeing over a period of 11 years we used repeated measurements to take into account the changes over time in both ses and child wellbeing indicators we hypothesised that neighbourhood deprivation affects neighbourhood social indicators of child wellbeing negatively methods study design and population this study uses a neighbourhoodlevel data design whereas ecological variables derived from neighbourhoods were used for the analysis no individuallevel data were used for this study hence the authors did not have access to individuallevel data throughout the study neighbourhoodlevel ses scores and neighbourhoodlevel data on social indicators of child wellbeing from 2005 until 2015 were used to perform repeated measurements in this paper a neighbourhood is defined as a four digit postal code area data from 3565 neighbourhoods representing 390 municipalities were initially eligible for analysis which represent all of the neighbourhoods and municipalities in the netherlands in 2015 social indicators of child wellbeing data on social indicators of child wellbeing were provided by defence for children a nongovernmental coalition for childrens rights this coalition monitors data on child wellbeing and is based on kids count a method adopted from the usa 32 neighbourhoodlevel aggregated data were provided on the proportion of children who were exposed to the unfavourable social indicators of child wellbeing data were provided per year from 2005 up to and including 2015 33 not all outcome measures were available for the full study period table 1 represents the main and secondary outcome measures social indicators available for the full period of eleven years were selected as main outcome measures social indicators available less than eleven years were included as the secondary outcome measures 20052015 unemployed youth the number of adolescents who are not working and looking for a job per neighbourhood divided by the total number of adolescents in the age group living in that neighbourhood 20052015 secondary outcomes social indicator of child wellbeing definition by defence for children years available child social services involved the number of children where child social services is involved per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20132015 teenage mothers the number of teenage mothers per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20052012 single parents the number of children who have a single parent per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20132015 reported and confirmed child abuse the number of children where child abuse was reported and confirmed per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20052014 children with a handicap the number of children with a handicap per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20122015 disadvantaged pupils the number of disadvantaged pupils per neighbourhood divided by the total number of children in primary education living in that neighbourhood 20052012 table 1 cont secondary outcomes social indicator of child wellbeing definition by defence for children years available children in special education the number of children in special education per neighbourhood divided by the total number of children in primary and secondary education living in that neighbourhood 20132015 children participating in sport clubs the number of children who are participating in a sports association per neighbourhood divided by the total number of children in the age group living in that neighbourhood 20142015 socioeconomic status the netherlands institute of social research publishes a ses score by pc4 every four years the scp is a governmental agency which conducts research into the social aspects of all areas of governmental policy this ses score indicates the social status in a neighbourhood compared to other neighbourhoods the ses score of a neighbourhood is calculated according to characteristics of its inhabitants education income and their position in the labour market a high score represents a high neighbourhood ses a low score represents a low neighbourhood ses the average ses score is around 0 with a standard deviation of 1 34 between 1998 and 2014 the overall social status in the netherlands increased but in 2016 it decreased the scp does not calculate a ses score for neighbourhoods with less than 100 households 34 because the ses score is calculated by the scp every four years the ses score of 2002 was assigned to the year 2005 the ses score of 2006 was assigned to the years 20062009 the ses score of 2010 was assigned to the years 20102013 and the ses score of 2014 was assigned to the years 20142015 respectively statistical analyses descriptive statistics were applied to calculate the median and 95 ranges for the ses scores and the outcome measures plots were created to depict the different social indicators of child wellbeing and explore their trends over time neighbourhoods with one or more missing ses scores were excluded outliers in the ses score were removed to better approximate a normal distribution of the data hence the lowest 25 of ses scores were removed after which 3531 neighbourhoods embedded in all 390 municipalities remained for the analyses separate plots were created to assess the linearity of the relationship between the social indicators of child wellbeing and ses score for the repeated measurements linear mixed models with random intercepts were used to estimate the association of ses score and the prevalence of social indicators for children with neighbourhood as analysesunit cubic splines were applied to the ses score when there were nonlinear relationships between ses score and the main or secondary outcomes the number of used knots needed differed per outcome measure maximumlikelihood estimation was applied to estimate model parameters twolevel hierarchical randomintercept models with neighbourhoods at level one nested within municipalities at level two were specified this allows for the incorporation of both neighbourhoodlevel and municipalitylevel characteristics as well as the adjustment for clustering within a neighbourhood itself and for clustering of neighbourhoods within a municipality the variance estimates of the random effects and the beta estimates of the fixed effects were reported with corresponding 95 confidence intervals a generalised linear regression analysis was used for all outcome measures the model used was a function of ses and year in which both the independent variable as well as the interaction with ses was added additionally a random intercept for neighborhood and a nested random effect for municipality was added sensitivity analysis and subgroup analysis sensitivity analyses were performed to assess whether weighing for population size per neighbourhood resulted in a better fit of the lmms the analyses demonstrated a better fit when this weighing was applied and was included into the models finally a subgroup analysis was performed in children of the age group zero up to and including two years old for this subgroup only five outcome measures were available for only one year the available outcome measures were reported and confirmed child abuse children living in families on welfare child social services involved single parents and children with a handicap generalised linear regression analyses were applied for the subgroup and the whole group as a comparison for all analyses the significance was set at alpha 005 two tailed analyses were performed using r studio version 10153 and specifically the lme4 package was used for the lmm results aggregated data of 3558 neighbourhoods was available table 2 features the characteristics of this dataset afterwards ses score outliers were removed after which 3531 neighbourhoods distributed over 390 municipalities remained for the final analyses figure 1 illustrates the increasing average prevalence of children living in families on welfare over time and the decreasing average proportion of delinquent youth and unemployed youth over time table 3 displays the mixed models for the main outcome measures after applying weights for population size the results of the initial analyses without applying weights are presented in supplementary table 1 the analyses of the main outcomes show that neighbourhood ses is inversely related with the prevalence of unfavourable social indicators of child wellbeing all associations between neighbourhood ses and the outcomes follow different curvesshapes children living in families on welfare shows an inverted exponential association a more linear association for delinquent youth and an inverted sigmoid association for unemployed youth table 3 displays the mixed models for the main outcome measures after applying weights for population size the results of the initial analyses without applying weights are presented in supplementary table s1 the analyses of the main outcomes show that neighbourhood ses is inversely related with the prevalence of unfavourable social indicators of child wellbeing all associations between neighbourhood ses and the outcomes follow different curvesshapes children living in families on welfare shows an inverted exponential association a more linear association for delinquent youth and an inverted sigmoid association for unemployed youth the results of the secondary outcome measures are presented in supplementary table s2 the ses score showed an almost linear association with child social services involved and an inverted sigmoid association with teenage mothers children living with a single parent and school dropouts the association of ses score with disadvantaged pupils represents an undefinable shape additionally higher ses scores were significantly associated with higher proportions of children participating in sports associations in a neighbourhood showing an exponential relationship the characteristics of the subgroup of children in the age group zero until two years old are presented in supplementary table s3 the linear regression analyses indicated an inverse association between ses score and reported and confirmed child abuse children living in families on welfare child social services involved and single parents similar associations were found in the linear regression analyses for the total population of 017 year old children in the equivalent years discussion we investigated the association between neighbourhood ses and social indicators of child wellbeing using repeated measurements with a one year measurement interval over a period of 11 years our results indicate that a lower neighbourhood ses was significantly associated with a higher prevalence of unfavourable social indicators of child wellbeing our findings indicate that low neighbourhood ses scores are strongly associated with higher proportions of children with unfavorable social indicators in a neighbourhood the steeper slopes for lower ses scores indicate that these findings are even more pronounced for neighbourhoods with the lowest ses scores for the main outcome measure children living in families on welfare the explained variance was 09 indicating that this outcome is very closely related to the neighbourhood ses scores furthermore for almost all outcome measures significant associations were found with explained variances varying between 044 and 097 this may be due to different municipal or governmental policies regarding child social services for younger and older children for instance with a stronger focus on social services for pregnant women and infants in low ses neighbourhoods 35 our data did not show a significant relationship between ses score and the secondary outcome measure disadvantaged pupils our findings are consistent with previous literature from other countries and emphasize the relationship between neighbourhood ses and unfavourable social indicators during childhood neighbourhood ses is often considered as a constant variable with our methodology and by using repeated measurements we took the possible variety in ses into consideration to measure our outcome our study results confirmed that a low neighbourhood ses is associated with unfavourable social indicators of child wellbeing such as child abuse living with a single parent delinquency less sports participation and teenage motherhood the relevance of this finding is illustrated by the fact that these social indicators are related to the problem solving ability and adaptive learning of the child and unemployment and social isolation of the parent 1421 chetty et al argued that neighbourhoods affect a childs longterm outcomes through childhood exposure effects the outcomes of people who move into a certain neighbourhood are likely to converge with those of permanent residents in the destination to which they move the longer a child lives in a certain neighbourhood the stronger the neighbourhood effects on their health related outcomes 20 this implies that neighbourhood indicators influence the outcomes of its residents rather than its inhabitants determine neighbourhood ses children living in families on welfare grow up in an environment where parents neighbours and other family members need to make an effort to get by leisure activities and sports are luxuries those children do not have access to if those activities are not enabled through neighbourhood services or by the municipality these children will lag behind on their peers delinquent and unemployed youth who live in an environment where careers are not supported or encouraged will negatively influence each other and their peers 32 our individual outcome measures are all influenced by different socioeconomic stressors and thereby show different slopes strengths and limitations a major strength of our study is that the vast majority of neighbourhoods in the netherlands were included in the analyses additionally we were able to use data over a period of 11 years enabling us to use repeated measurements and create a more robust estimation of the associations while taking variations over time into account similar associations were found in our sensitivity and subgroup analyses indicating that our findings are robust a limitation of this study is the absence of personallevel data with personallevel data it would have been possible to create a threelevel model taking the interpersonal variation of people living in a neighbourhood into account another limitation of this study is that we were not able to analyse the effects of time trends in ses on health and wellbeing of its residents it is hypothesised that for instance an increasing neighbourhood ses benefits the health of its residents it is likely that this effect is delayed showing a socalled lagging effect on health outcomes 36 in order to assess the effects of socioeconomic trends over time larger longitudinal datasets are needed including data from multiple decades of time and personal level data including data on residents moving into and out of a certain neighbourhood 2036 in our literature search we did not find any studies showing no relationship between ses and the wellbeing of children and youth in conclusion future studies should consist of larger longitudinal datasets and should attempt to take the interpersonal variation into account for example a longitudinal study into successful and unsuccessful policies and implementation processes of helpand care facilities when it comes to individual data studies a qualitative semistructured interview approach combined with a qualitativequantitative survey could be considered conclusions this study underlines the relationship between a low neighbourhood ses and a high proportion of children with unfavourable social indicators of child wellbeing in a neighbourhood including stronger effects for lower ses scores this contributes to the body of evidence that neighbourhood ses is an important factor related to health and social indicators of child and adolescent wellbeing and wellbeing in later life the general ecological hypothesis states that as the number of stressors in a neighbourhood rise distress among those living in the neighbourhood increases 37 38 39 a high proportion of unfavourable social indicators of child wellbeing in a neighbourhood could be a result of these stressors and contributes to widening of the gap between people of different socioeconomic status although neighbourhood ses is largely driven by the characteristics of its adult inhabitants it also affects a childs ability to develop to its full potential which renders inequality between children growing up in low or high ses neighbourhoods attention must be paid to these inequalities specifically in children by governmental social and healthcare institutions in order to provide equal opportunities for all data availability statement the data will not be shared in accordance with the contract with defense for children the data on social economic status are publicly available data can be provided by the erasmus mc upon request supplementary materials the following are available online at 103390ijerph182312661s1 table s1 primary analysis for the main outcome measures estimates of ses score and social indicators of child wellbeing n 3531 table s2 secondary outcome measures adjusted for the number of children or adolescents living in a certain neighbourhood n 3531 table s3 characteristics of children in the age group 02 years old n 3541 table s4 abbreviations

background living in deprivation is related to ill health differences in health outcomes between neighbourhoods may be attributed to neighbourhood socioeconomic status ses additional to differences in health neighbourhood differences in child wellbeing could also be attributed to neighbourhood ses therefore we aimed to investigate the association between neighbourhood deprivation and social indicators of child wellbeing methods aggregated data from 3565 neighbourhoods in 390 municipalities in the netherlands were eligible for analysis neighbourhood ses scores and neighbourhood data on social indicators of child wellbeing were used to perform repeated measurements with one year measurement intervals over a period of 11 years linear mixed models were used to estimate the associations between ses score and the proportion of unfavorable social indicators of child wellbeing results after adjustment for year population size and clustering within neighbourhoods and within a municipality neighbourhood ses was inversely associated with the proportion of children living in families on welfare estimates with two cubic splines 359 ci 399 319 and 300 ci 333 267 delinquent youth estimate 026 ci 030 023 and unemployed youth estimates with four cubic splines 041

background kenya is among the countries with exceptionally high hiv epidemic in the world with 16 million people living with hiv in 2016 and ranked fourth globally 12 overall the hiv epidemic in kenya is driven by sexual transmission and is generalized among all sections of the population including children young people adults women and men 3 whereas a disproportionate number of new infections occur among specific population groups such as female sex workers people who inject drugs men who have sex with men men in the general population also carry a considerable burden of hiv infection with approximately 4 percent estimated to be living with hiv hiv testing services is a major feature of kenyas hiv response 4 as it offers timely linkage to care and treatment prevention of onward transmission to sexual partners and reduction of risky behaviors 5 6 7 8 however major challenges in the hiv care cascade remain for men 9 10 11 12 13 14 15 16 17 18 recent populationbased evidence from kenya demonstrated that 53 of women had tested for hiv in the past 12 months and received their results compared to 45 of men 19 further it is estimated that 35 of all people living with hiv in kenya are men and that approximately 33 of new hiv infections occur among male population 2021 similar patterns have been observed in other regions of subsaharan africa where few men test and access hiv services late in the disease process 18 22 23 24 25 men are less likely to access health services in a timely manner compared to women due to several factors which by extension can limit hiv testing coverage existing evidence suggests a variety of possible barriers to uptake of hiv testing among men in ssa including individual personal factors such as gender norms 26 fear of results 16 17 18 stigma and discrimination 1419 low perception of risk 21520 and fear of disclosure facilityrelated factors such as provider attitude and confidentiality 27 inadequate supplies and equipment 28 have been documented to hinder access to testing services 2930 diverse structural factors such as suboptimal targeting inadequate public information have also been noted to obstruct access to hiv testing 28 in addition to these barriers hiv testing is a key defining event for most people because of stigma and fear and uncertainty associated with a positive result 3132 hence in promoting hiv testing uptake a vital question is how to position testing and the potential negative effect of learning one has hiv against the benefits of learning ones status 31 part of the unaids 909090 strategy to counter some of the barriers to testing outlines the importance of reducing hivrelated stigma addressing the fears of testing promoting hiv testing social norms providing options for rapid and nonbloodbased hiv tests and ensuring nonjudgmental and culturally competent hiv counselling and testing services 13 33 34 35 36 yet with these vibrant strategies data suggests that neither testing nor initiation to treatment has reached optimal status in ssa 22233738 and specifically among men in the region 1417 39 40 41 there is therefore a need for interventions to enhance hiv testing coverage for men to help with identification of new hiv cases and early initiation into care formulating such interventions requires an understanding of the context of testing as well as existing barriers and facilitators to hiv testing from the perspectives of both men and health providers while there is some regional evidence and information on the context barriers and facilitators to hiv uptake among men such evidence is severely limited or nonexistent in kenya the few studies on hiv testing status among men in kenya largely focus on their role in the prevention of mother to child transmission services or oral selftesting and less on men as hiv testing clients the updated hiv testing and treatment guideline in kenya recommend expansion of hiv testing through selftesting and partner notification provider initiated testing in addition to rapid initiation of arvs 42 given the low uptake of hts among men there is a need for evidence on factors surrounding hiv testing to better understand the motivations and drivers of hiv testing among this segment of the population this study was anchored a sociological concept positive deviance that aims to encourage desirable behaviors by learning from individuals who are deviant in a positive sense thus the selection of hiv positive men in this study was based on the need to understand their motivations to test and determine the unique attributes or strategies that enable them test than their peers who are untested or hiv negative despite facing similar challenges using qualitative data this paper presents an indepth understanding of the context perceived barriers and facilitators of hiv testing among men who tested early or late in an urban setting in kenya we also sought providers perspectives on mens uptake of hts to document providers views on health facility and structural factors and health seeking behaviors of men accessing services at the facilities a highly nuanced understanding of mens experiences with hiv testing can inform the design of targeted interventions aimed at improving the uptake of hiv services for specific population subgroups methods study design this was a crosssectional qualitative study that was conducted as part of usaidfunded project soar portfolio entitled improving uptake of hiv testing services and linkage to care after diagnosis in kenya conducted in 2018 to understand the motivations and drivers for getting tested the study was implemented in two phases in phase 1 we implemented a mixed method crosssectional study that entailed scoping of hts sites surveying men seeking hiv testing at hts centers and qualitative indepth interviews with hivpositive men and counsellors providing hts services the objective of the study was to identify sitespecific characteristics that contribute to attracting male clients for hiv testing to examine mens knowledge attitudes and practices around risk behaviours and hiv testing and to understand their motivations and drivers for getting tested in phase 2 we developed and evaluated a simple posttest assessment tool for hts for counsellors to use to improve hts services 43 as part of phase i activities idis were conducted with hiv testing counsellors and men living with hiv who were on care in eight health centers the participating health facilities were selected based the number clients accessing hiv testing services selection of facilities based on the number of clients accessing hts and geographical location was done to try and determine whether access to services by men is enhanced or impeded the facilities client load and location existing literature has documented stigma and discrimination confidentiality and long wait time as barriers to hts services 141927 we conducted a mapping and scoping of health facilities providing hts services in nairobi county a total of 124 out of 381 facilities providing hts in nairobi representing the four tiers of health care service delivery in kenya were purposively selected based on the following characteristics client load total number of males versus female testers catchment area and hts type the services statistics data was used to categorize centers with highand low client load we classified high volume hts sites as sites that had �45 of clients accessing hts being male while low male volume categorized as facilities with less than 45 percent of clients accessing hts services being male this cutoff was based on the evidence that more women than men were likely to be tested for hiv 44 the health facilities serve patients families communities and key populations and they cover emergency preventative hospital diagnostic and primary care since the promulgation of the new kenyan constitution in 2010 management of these health facilities shifted from central government to the city county government of nairobi the idis focused on reasons for testing early or late knowledge of hiv transmission perceived risk risk behaviors stigmatizing attitudes towards people living with hiv gender norms time taken and process of arriving at a decision to test personspeers consulted and expectations prior to testing and preparedness for the result the study protocol was reviewed and approved by institutional review boards of the population council and kenyatta national hospitaluniversity of nairobi ethics and research committee and national commission for science technology innovation participants were given a modest reimbursement of ksh 300 to cover their transport costs participant recruitment recruitment of providers the hiv testing counsellors who were directly involved with testing services in eight study sites were purposively selected following consultation with facility incharges eligibility criteria for participation in the indepth interviews for the counsellors included being aged 18 years or older proficiency in kiswahili or english participation in the hiv testing program at least 4 months prior to the interview and abilitywillingness to provide written consent recruitment of men living with hiv mlhiv who had received their positive diagnoses and accompanying cd4 counts six to 12 months prior to recruitment were identified retroactively by examining clinical records and identifying 15 men whose cd4 count was �500 cellsmm around the time of diagnosis and 15 men whose cd4 counts were 500 cellsmm at the time we recruited approximately 34 mlhiv from each of the eight facilities other eligibility requirements for the mlhiv included being aged 18 years or older proficiency in kiswahili or english abilitywillingness to provide written consent and residing in the study area for at least 1 month prior to the interview the counselors obtained client information contacts provided a brief explanation of the study and invited them to visit the facilities and participate in the interview overall the refusal rates were below 5 data collection indepth interviews were conducted by study team members trained in qualitative data collection with each facilitator recording the conversation and taking short notes when needed all participants provided information on age marital status education occupation duration of knowledge of hiv status and whether they were residents of nairobi interviews lasted approximately 4060 minutes and were conducted in kiswahili english or a mixture of both depending on participants preference all discussions were digitally recorded transcribed and translated into english efforts were made to ensure confidentiality during the study participants names or any other identifying information were not recorded and the interviews were conducted in private settings away from audio and visual disturbance data analysis qualitative interviewers wrote initial impressions of key findings observations and issues for further exploration before transcriptions were done following transcriptions two qualitative analysts first read through the transcripts independently to identify broad themes and generate descriptive codes and categories the codes were then compared to resolve discrepancies through discussion and consensus and a final code list was developed the analysis was conducted iteratively and focused on the context barriers and facilitators to hivtesting results sociodemographic characteristics of study participants we conducted indepth interviews with 30 mlhiv who received a positive diagnosis within a period of 612 months and eight hiv testing counselors directly involved with the provision of testing services at eight facilities in nairobi mlhiv the mean age of all mlhiv was 342 years most participants were married were residents of nairobi city had some primary or secondary education and were employed most in the informal sector counsellors the mean age of all counsellors was 36 and the mean number of years in service was 61 with a standard deviation of 400 all participants had minimum o level secondary education as well as hiv counselling training most counsellors were females the context of hiv testing in this section we present data on the context leading to hiv testing among mlhivs including timing of conducting the test decisionmaking process including people consulted and the actual hiv testing experience as these can provide understanding of the decisionmaking processes which can inform maletargeted interventions overall as previously noted we documented minor differences in the experiences of hiv testing among early and late testers time taken to arrive at a decision to test while some men took a short time to test after making up their mind to test most took one or more decision to test after one or more months was often linked to concerns around cost of services stigma and poor partner relations among the specific reasons given for testing late were cost of conducting an hiv test and scouting for facilities which were far away from place of residencework the hospital is far from where i live and sometimes when people know you are infected they see you as useless and as i was explained even if we meet on the streets they wont expose me we will just exchange greetings and life goes on i was assured that i can come for medication or treatment any time indecision to test and poor interpartner dynamics prolonged the decision and timing to test participants were reluctant to initiate discussions with their partners for fear of backlash therefore some participants used a variety of strategies to initiate discussion to test it took me a long time we had been talking with my wife and she always confidently told me she and the children are okay it took me about two weeks i first saw the card and ignored and since i didnt want to make her angry i waited for some time when i eventually asked her she responded that she is negative and her children consultations and actions taken prior to testing participants were asked whom they talked to or sought advice from before testing for hiv and overall minimal consultations were made prior to testing although whenever discussions occurred it was with partners or other close relatives who offered support to test yes my brother he works with hospital he accompanied me on his way to work and encouraged me to go and get tested and told me of case scenarios at his place of work since he worked at a hospital he saw several people who were living with hiv and went about their business normally in view of minimal communication prior to testing nearly all participants were unaccompanied when they went for testing potentially portraying a desirepressure to demonstrate being in control 45 the few men who were accompanied to the facility were too sick to reach the facilities by themselves generally disclosure to partners occurred after the hiv test was conducted and test results confirmed hiv testing experience most participants mentioned certain standard procedures prior to and after testing which included being asked for permission to test as well as receiving counselling before and after testing the preand posttest counselling was well received by a clear majority of men most men were happy with the inperson interactions with providers and as a result they affirmed embracing a positive attitude towards life and readiness to follow antiretroviral treatment schedule first the lady i found here handled me very well she received me very well in a manner that really impressed me even during testing she encouraged me she gave me a very good example i will never forget she told me there is someone who might have left his house today left things nicely but on reaching the road he got hit by a car and died so i felt a bit relaxed and i accepted i have even gone for classes three times the teacher taught us very well i have not seen any issues concerning the services here however there were a few men who expressed dissatisfaction with the counselling process mainly due to impatience arising from the time taken to conduct counselling i think they need to be efficient so we can also go back to work for me i call beforehand and ask if i can go at a specific time if they are free i dont like to sit and wait barriers to hiv testing in total during our analysis seven themes were identified as barriers for hiv testing analysis showed no major differences in the emerging themes from participants that were categorized as early and late testers based on their cd4 cell counts the identified themes include perceived providers attitudes wait time and inconvenient hiv testing clinic times low perception of risk limited hiv knowledge anticipated stigma and discrimination location and set up of health facilities and fear of having a positive hiv test perceived negative providers attitudes prior to visiting health facilities several participants admitted to being hesitant to visit the health facility to have an hiv test done because of doubts about how providers would handle them due to the information they had heard about the conduct of providers mostly participants had negative information on providers behavior and generally this was based on hearsay own past experiences or their partners experiences during childbirth thus real or imagined negative attitudes of providers coupled with the uncertainty of facing an hiv diagnosis made several men hesitate to visit the hiv testing center the commonly held notion about negative behaviors of health workers was evident from participants reference to the health professionals as rough unkind or time wasters the following quotes depict the common view shared by participants yes i was worried because i always heard that there are some doctors who are always rough and so i was wondering what if i get in there and find such doctor it is not a must i get tested no that thing is so important because where i went if it were not for those doctors and the way they talk to people you know there are times when you hear that the doctors are not so kind like for example when my wife gets children she will tell you the way the doctors are rude but for those who offer these services are very good although participants held negative perception about providers prior to testing the views changed after the test for many and participants highlighted their satisfaction with services when they accessed hiv testing services and had interacted with the hiv testing staff i used to dislike them and i wondered what they had to tell me i only made my way here because of being ill otherwise i thought they were time wasters little did i know that they were good people with good intentions towards ones health offering good advices but as far as the staff and the center was concerned i had no doubt that anything to do with my status would be leaked but as far as the environment social relationships was concerned i would be lying if i said there was no issue wait time and inconvenient client hours the opening and closing times and long queues at health facilities offering hiv testing services hindered men from accessing testing services in a timely manner the service hours of facilities offering hiv testing services and delays due to high client volume were cited as impediments for testing due to a conflict with work schedules typically most participants work for a 56 days from 8 am to 5 pm with a onehour lunch break while some have evening shifts when most facilities are closed given that mens work schedules conflict with that of facilities only a few men can access testing services during the day when most facilities are open thus concerns about work schedules time availability and access to quality hiv testing services were frequently mentioned as barriers to hiv testing you can come here and take three hours you should just come pick your drugs and go so if you had work you can go and do it i think that will be better men are work oriented so with perception they feel like when they come for hiv testing it is something that just involves pricking and result interpretation what makes them unable to get the services appropriately is the time factor they believe it just has to do with pricking and interpreting the results low perception of risk for people to take appropriate actions to protect themselves against hiv infection they first must perceive themselves as potentially being at risk of becoming infected due to exposure to risk behaviors however participant interviews show that some men took time to test because they had a low perception of risk and held the belief that they had a small chance of getting infected with hivthey frequently talked about lacking selfawareness of their risk despite engaging in unprotected sex with casual partners and often under the influence of excessive alcohol consumption as cited by these mlhivs when i was indulging in risky behavior sex without a condom with a casual partner most of the time it was in the heat of the moment okay not most of the time but the only instances when i needed to clear my mind under the influence of alcohol and you know most of the time when such things happen you are not aware or in control whether i was at high risk or low risk or no risk i would not have concentrated on it seriously because most of the time i used to be intoxicated furthermore health providers maintained that despite repeated exposure to high risk situations some men didnt bother to test because they thought they were safe owing to the information they received from their regular sexual partner that those partners were hiv negative we also get some female or some male who comes and says once na si bibi yangu alipimwa why should i get tested they will tell you my wife was pregnant and tested for hiv i know my wifes status is my status knowledge of hiv as existing evidence suggests common reason for hesitating to be tested for hiv centers on limited knowledge of hiv and misconceptions of being infected with hiv 46 47 48 while most men knew about basic information about hiv it was clear that detailed information men had on hiv was insufficient likely due to where they initially obtained the formation when probed for what they knew about hiv most men talked about the lifethreatening condition of advanced hiv disease fear of being infected with hiv and how fatal hiv is without elaborating or discussing critical underlying issues related to hiv testing such as mode of hiv acquisition transmission prevention and management as characterized in the following quote yes i knew if you contract it you would not even last three months before you are dead i knew it killed very fast i did not have a lot of information but i knew there are medications which people take i also knew it is a killer disease however one participant admitted to totally lacking information about hiv and only got to know about it when he visited the health center and got tested responding to a question on what he knows about hiv the participant replied that i was blank i did not know anything i never even thought there is hiv and aids i learnt of it after i tested positive most of the information about hiv was obtained from a variety of sources including school seminars and from individuals such as herbalists medical professionals and musicians a few men spoke of seeking hiv information from the radio television or internet after they had developed health problems on the streets herbalists talk to people on the roads and they also talk a lot about hiv there are those doctors who always passed by saying it was better to always know your status how you live if you are hiv positive so that you are able to know how to take care of your family perceived hiv stigma and discrimination emerged as a key determinant of hiv testing despite hiv being in its third decade there still appears to be high levels of stigma that limit access to hiv services 1726 49 50 51 narratives from participants show they were concerned about what people might say if they found that they were hiv positive in view of this some men were concerned about the reaction they would receive from their peers close relatives and health providers they described fears about disclosure of their hiv status fear of being seen at the facility including physical appearance due to hiv disease and rumors of deteriorating health however selfdoubt from negative judgment and shaming emerged as a consistent theme in the narratives location and set up of facility closely related to stigma and discrimination is location and set up of facility which was a key consideration in choosing where to test most men reported that they elected to test at a specific facility owing to its privacy or for being located far away from where people know them men kept away from health centers or hiv testing sites which were close to where they lived or where they suspected they might be known to or recognized by health facility staff consequently to identify a suitable health facility some men ended up incurring transport money to access services deemed private and confidential services for me this hospital is far from where i live and as i explained to you even if we meet on the streets they wont expose me we will just exchange greetings and life goes on i was assured that i can come for medication or treatment any time i heard of that clinic before i knew of my status i heard from a colleague that those ladies who sit outside that clinic usually go to get arvs antiretroviral drugs and i thought to myself if people have that perception if i go to a clinic near home i will be found out coupled with location the physical structure and set up at the facility was also a key consideration before testing in general men tended to avoid facilities with isolated testing sites or open examination rooms which they feared could expose them and be recognized by other people at the facility a finding which resonates with previous studies done in subsaharan africa 255253 fear of having a positive hiv diagnosis and access to testing services for most men the dominant fear was a positive hiv test which appears to be a strong deterrent for testing potential negative consequences of a positive diagnosis cited by participants included losing their partner isolation due to stigma anxiety and on the extreme end suicidal ideation fears expressed in reaction of receiving a positive diagnosis was regularly expressed by both men and health providers some men tell you if i find out i am hiv positive i will die right here there was another one last week he said madam if i know my status right now am going to kill myself similarly the fear of the unknown as some providers put it was intricately linked with late entry into care and was often cited as a reason for high mortality among men they have the fear of the unknown i can say some have the fear of the unknown that i get up and just for a testing ahh that one no so they fear hiv test they accept when they are told youre testing malaria you test even the prostrate but not vct in addition health providers frequently talked of difficulties implementing providerinitiated testing and counselling strategy mostly due to the challenges of convincing men receiving general services to have an hiv diagnosis providers found that for the most part some men accessing general health services were uncomfortable and ultimately became resistant when they were advised to undergo hiv testing okay about that one you know about pitc you know those ones have come for treatment they have not come for testing other men even can just come and tell you i am not ready for that please madam so you know you cant force somebody that they should be tested so you just tell that person that when you are ready its good to come thats all the narratives also suggested that some men believe that if they are in good health they do not need to undergo the test one health professional reported that i dont know if it is correct but men find it hard to visit hospitals if they are not sick so men are supposed to be persuaded and talked to convince them for testing but it is generally hard for them to decide on their own facilitators of hiv testing understanding factors that facilitate hiv testing can help programs focus on important aspects of hiv testing services participants discussed factors that can enhance hiv testing both at the health centers and within the community however across themes there were minor differences among early and late testers these factors fall under two categoriesindividual level factors and health facility factorsand generally focusing on the following themes some of which have been documented in other studies high risk perception 6143654 severe illness awareness of partners hiv status privacy and confidentiality 2955 anticipated quality of services 23 availability of providers supplies and equipment 23 flexibleextended opening hours 56 and preand posttest counselling high perception of risk some mlhiv who did not delay or hesitate to test reported that the motivation for testing was being aware of the risk of hiv infection following exposure to any of the known high risk activities such as unprotected sex multiple sexual partners inconsistent condom use they also felt that having sex under the influence of alcohol placed them at heightened risk of being infected with hiv as illustrated by these men i had many girlfriends and i was not very careful i was influenced by drinking habits like for two years before getting tested i was going through some sort of depression phase and throughout this phase i exposed myself to a lot of risky behaviour you know including indulgence in alcohol consumption and risky sexual behaviour health providers also mentioned that a recognition of their high risk exposure was the motivation for seeking a test among early testers after engaging in a highrisk activity a combination of worry and fear follows which leads them to get tested as one provider noted and some are open and some say i know i have been here and there with different partners so am worried am worried i just want to know thats why they want quick service i want to be tested just to know he is worried and stressed severe illness some participants especially the late testers arrived at a decision to undertake an hiv test after experiencing severe illness persistent and often unexplained illness motivated or forced some men to seek testing to know what they were suffering from in many cases with deteriorating health this process was also driven and encouraged by health providers or close family members i had a problem with my health so they providers told me i must be tested for hiv that is when i went and got tested and after that they asked if i would be willing to use the drugs because i was found to be positive similarly providers alluded to the fact that men are reluctant to seek health services whereas this was the case unexplained and prolonged illness as well as suspicion of having a sexually transmitted infections drove men to seek health services including hiv testing you know most men when they feel very ill is when they go to the hospital but if they are not very ill you wont see them in the hospital most of them or some of them it is the illness maybe like they have a headache or stomachache which makes them to come by the way and here in health facility name we also have the stis they are making people to come so much if one has an sti they feel like if i have an sti i must be having hiv so you get them coming more often by the way awareness of partners hiv status participants felt that knowledge of a partners hiv status was a catalyst for testing regardless of how participants became aware of their partners hiv statuswhether through direct disclosure by the partner or through their own suspicions about the partners healthstatusalmost always this was followed by a sense of urgency to go and test its because i learnt that my partner was positive and that we are actively engaged in sexual activity and so i thought there was no reason for me to shy away from this and thus i convinced myself that i needed the testing in addition providers emphasized that men were more inclined to test when they entered a new temporary or permanent relationship some who are married come because they want to because hes being troubled by the wife and so i want to get another wife and since i have children or my first wife died i dont want to bring them a sick mother so they come for testing because most them for them to come i told you they have a reason you see so many of them they fear hiv confidentiality and privacy two aspects of privacy and confidentiality were noted first participants suggested that health facility staff should be professional and always endeavor to conceal patient information this issue emerged out of the recurrent concerns raised about unexplained and negligent disclosure of clients hiv status to other people one participant said i was at name of facility where the doctor accidentally broke the news to my mom it would really help if the hospitals first asked rather than saying it out aloud i am so fortunate to have understanding parents and people around me perhaps if things were a bit different saying it out aloud would not have been an issue for the patient confidentiality is an issue second participants felt that testing sites should be in discreet locations that can best protect their privacy several men as well as providers suggested the need for an enabling environment in facilities that inspire clients confidence to access hiv testing services participants raised concerns about easily identifiable locations for offering hiv services within facilities that lacked both visual and audio privacy okay in my own opinion i think it is all about the privacy that can make one prefer other options because when you get to that room everyone will know this person is infected for example for this place the room that we go to is next outpatient area so you will find that we are even sharing the same bench with them so when you get to the room other patients just know you are going for hiv services and people will just starting talking about you going to hiv center anticipated quality of services clients views were sought on testing services and what they thought were the best ways for health facilities to promote hiv testing and treatment services for men based on responses to this question three key aspects emerged highlighting important features of service delivery these were quality privacy and friendliness of services which participants felt were critical in the choice of a facility friendly services mean personalized services and the service providers see you as a friend it is a place where you are confident that you will get the services that you want i even told my wife to stop going where she goes because they are made to line up in the open where everyone can see them i even brought her here because they are keen in maintaining confidentiality and not put on a bench like rubbish further participants interpretation of quality of services entailed the whole spectrum of services provided at facilities from initial contact with staff at the reception area interactions with providers in different departments to availability of hivrelated expertise in my opinion friendly services would mean that the moment a client comes in one way you can help such a person would be even in a case when they have come when they are very sick you know at times there are people who can come in when they are really in a bad state healthwise then you hear the doctor asking where were you that you waited too long to look like this how are we supposed to help you you realize there someone may lose hope because they will be telling themselves you see even the doctors have seen it that i will not make it even if i am given the drugs so there is really no point of taking the medication i would say when you walk to any health institution the first impression is at the reception before you even go to see the doctor and explain your problems like if i have to get medicine and the receptionist is rude the distance starts with the first stage which is the receptionist then goes up to the doctor what is the reaction of the doctor how does he take it how does he advice you yeah availability of supplies providers and equipment was also reported as an important factor influencing access to and motivation for hiv testing among men it should have plenty of kits drugs and enough doctors so that patients do not queue for long it is not good when they are few doctors are there but there are no medicines and even for other illnesses flexibleextended opening hours as noted earlier current service hours at health facilities prevent working men from accessing testing services due to their work schedule almost all participants suggested that operating hours at the facilities should be made flexible to accommodate their tight work schedules with proposals for facilities to provide an allround 24hour service to address the twin concern of conflicting work schedules and the provision of discreet services as cited below they should make these hospitals operate 24 hours because this one is a big hospital the reason why im saying that is because there are some people who work in daytime up to very late and when they come here they dont get services because the doctors and the nurses are gone i guess night shift at least some guys could be coming and popping in and you know most of the guys do not want to be seen entering this hospital and maybe some are working for instance saturdays and sundays preand posttest counselling standard preand posttest counseling services provides information on the technical aspects of testing and the possible personal health social and psychological implications of being diagnosed as either hiv positive or hiv negative participants felt that counselling should extend beyond this and include instilling confidence to disclose their status to their partner enhanced couple testing enabling clients to cope with the hiv diagnosis and preparing individuals for art initiation it is helpful if it was not for the counselling i had decided to chase away my wife they told me to take it easy and i can live positively i was only thinking about death before i was tested i was counselled by the doctor and by that time i decided that if i turn out positive i will just take it normal i will start medication and i will follow the doctors advice you must continue with life i believe it is not the end he really helped me because by the time he asked me whether the result would be positive or negative i just accepted discussion to date in kenya a large body of research on hiv testing among men has focused on the quantitative measurement of pmtct 57 58 59 60 male involvement 61 62 63 and oral selftesting 64 65 66 with limited data on standard hiv testing offered within regular health care settings studies utilizing qualitative approaches to document insights and perspectives of men on hiv testing experiences are lacking in kenya yet such data offer rich lived experiences that can better provide the context and experiences of hiv testing and potentially help improve services this paper utilized indepth interviews with mlhiv and hiv testing counsellors to understand the drivers of hiv testing among men in the city of nairobi there are several strengths of this study first we conducted the interviews with participants who were recently diagnosed with hiv and were on art many of whom during interviews recalled their recent hiv testing experiences rather than querying hypothetical experiences to document their positive deviance behaviors second we conducted the study in health facilities with differing characteristics and in a setting with a moderate to high burden of hiv among the general population which allowed us to elicit rich experiences around hiv testing that possibly influence hiv testing decisionmaking process clients accessing hiv testing services are confronted with different challenges in deciding where to take an hiv test and therefore by documenting clients perspectives from diverse settings we provide a nuanced understanding on mens perceptions and reasons for testing at the facilities third the study obtained data from both mlhiv and hts counsellors ensuring triangulation of themes hence to design targeted interventions aimed at improving uptake of hiv services it is essential to have a nuanced understanding of mens experiences with hiv testing servicesthe context barriers and facilitatorsfrom clients and providers our findings highlighted several barriers and facilitators to hiv testing among men most of the key barriers to testing were at the individual and health facility level which largely intersected with stigma and discrimination and likely affected timely access to hiv testing services in addition with the hiv epidemic in its third decade in the country the assumption was that knowledge of hiv testing was near universal and widely accessible everywhere yet our findings showed that critical knowledge gaps still exist thereby delaying hiv testing and entry to care our findings are consistent with other studies in africa 67 68 69 that further show that the risk perception of hiv infection was low among some men as they did not view themselves to be at risk even when engaging in high risk behaviors or altogether lacked selfawareness of risk due excessive consumption of alcohol in their study velloza et al 70 found that individuals who used alcohol had twice the odds of art nonadherence compared with those who did not use alcohol while prevalence of alcohol misuse based on auditcage in ssa is estimated at 328 71 and 317 268 372 in kenya it was found that the prevalence rates for alcohol consumption was higher in men than in women 72 the inability to identify exposure to risk or downplaying exposure to risk can have far reaching consequences to an individual or their sexual partner health due to repeated exposure to risk arising from lack of knowledge or agency to seek services as a result hiv programs need to actively incorporate alcohol related interventions to mitigate the effects of alcohol on personal risk especially helping men better assess their risk of hiv a common view among participants was that most working men find it extremely difficult to access hiv testing services during normal working hours due to conflict with work schedules this issue is amplified with the desire to seek services far away from areas of residence thus a sizeable number of working men may miss out on critical hiv testing services in health facilities owing to work commitments unless they identify facilities with flexible operating hours are convenient for them mens work commitments may also affect their ability to use communitybased hiv testing services our findings are consistent with research findings from other subsaharan african countries including zambia south africa and burkina faso where overall hiv testing rates for men is disproportionately lower than among women 101173 this suggests that men in the ssa region may face similar barriers to hiv testing at different levels including at the individual healthcare system and interpersonal levels where perceived negative provider attitudes location and set up of health facilities inconvenient operating hours and low perception of risk create barriers to hiv testing and increase the risk of hiv infection 912172550 more so our findings show that site location setup of facilities perceived providers attitudes privacy and confidentiality overlap with a strong sense of anticipated stigma often participants were conscious of provider attitudes especially where and how facilities were set up mainly due to concerns around their privacy and confidentiality which points to deep rooted fear of testing or being identified to be hiv positive stigma and discrimination has been found to affect access to health services and nondisclosure of health conditions owing to fear of being isolated or rejected which may result in nonadherence to or low uptake of medical advice 49 our findings document several instances where participants access to testing services was delayed by concerns around stigma and discrimination although numerous national campaigns to promote hiv testing in kenya have been implemented countrywide in the past it appears stigma is still pervasive and continue to hinder access to testing services stigma and discrimination should also be addressed nationally and within the communities and at the health centers as it appears stigma in all its forms is given less emphasis in hiv programs this likely points to a gap in effective strategies to address stigma and discrimination without which the attainment of the 909090 country targets might be in jeopardy a review of a study conducted in south africa more than a decade ago showed that hivrelated stigma drives the pandemic out of the public view a phenomena which is still occurring among clients seeking hivrelated services 26 similarly evidence from other settings 8187475 demonstrate that stigma discrimination and fear of having a positive hiv test result are critical factors for both testing as well as linkage and retention in hiv care among men 1750 interestingly despite uncertainties of how providers would handle them there was a significant change among mlhiv perceptions about provider attitudes before and after undergoing hiv testing and related counselling prior to hiv testing it appears negative perceptions about provider attitudes impeded the uptake of testing however these perceptions appear to improve due to the quality of interactions with providers and services received thus programs should use the positive client experiences to enhance posttesting actions including enhancing referrals and linkage to care and other support services however in their findings from providers interviews in western kenya genberg et al 76 found that health system factors impact patient engagement in hiv care due to work environment that constrained providers ability to deliver highquality hiv care and encouraged negative patientprovider relationships studies among other key population groups such as men who have sex with men have shown that access to hiv care is impeded by hivrelated stigma lack of access to friendly health services economic and social challenges due to stigma difficult relationships with care providers and discrimination at the clinic and in the community 77 the indepth interviews with men and counsellors identified several facilitators for the uptake of hiv testing high perception of risk severe illness partners hiv status at the individual level and perceived quality of services including role of counselling facility opening hours and availability of privacy and confidentiality and availability of providers supplies and equipment at the facility level content identified in the themes in the kenyan context and specifically relating to male testing that have not been well documented in previous studies include severe illness knowledge of partners status and the role of preand posttest counselling in facilitating testing and enhancing coping mechanisms and linkage into care further exploration is needed to assess reasons for mens delay in seeking hiv testing services and the context of prolonged ill health strategies to enhance disclosure of hiv status to partners is needed both at the individual and health facility level to improve couple counselling and hiv testing in general although preand posttest counselling largely provides information on the technical aspects of testing our findings demonstrate that its benefits go beyond the mere provision of hivrelated information to shifting attitudes and enhancing early initiation to treatment and subsequent linkage and retention in care most experiences of early and late testers overlapped across themes implying that the challenges men face before during and after testing might be crosscutting among different categories of men however further exploration of the barriers to testing is needed to objectively identify their correlation with hiv testing moreover in view of our findings there is need to address gaps in risk perception hiv knowledge and access to accurate information couple communication stigma reduction and health awareness and agency to access health services a focus on understanding the facilitators for hiv testing is also needed to better understand how these factors can be amplifiedapplied in hiv programs since the design of hiv testing interventions can be context specific there are a few study limitations to note given that many participants were recruited from the health facilities it is possible that these participants face fewer barriers to accessing hiv prevention and sexual health services compared to those in the community who do not test or those with no or limited access to services also our sample size is small and the perspectives of men presented in this article might not be representative of all the men accessing hiv care at health facilities in nairobi and kenya in general further given the limitations of qualitative inquiries and the fact that sampling of participants focused on specific subcounties in nairobi our findings may not be generalizable to all men in kenya and hence should be interpreted with caution in conclusion owing the importance of hiv testing in hiv prevention and the fact that it provides an important entry point for care for persons newly diagnosed with hiv enhancing access for hiv testing services especially for men is a critical first step in linking them into care and addressing the hiv epidemic our findings identified multilevel barriers and facilitators for uptake of hivtesting and provided a summary of implications in public health practice hiv programs need to address the context barriers and facilitators for testing to increase uptake of testing and to link mlhiv to care the findings also suggest that it may be prudent to revisit policies and guidelines relating to testing and treatment with a view to aligning them to with some of the gaps and opportunities identified in our findings and other related research for example pitc may be effective when men present themselves for treatment during severe illness but there is a need to specifically address mens apparent poor health seeking behavior and specific behavior relating to uptake of hiv testing and treatment services also there is a need for more robust studies to investigate the complex interactions of the barriers and facilitators for testing in the current context in the country if kenya must meet its 909090 strategic goals data are available from figshare 11086454

hiv testing services are an important component of hiv program and provide an entry point for clinical care for persons newly diagnosed with hiv although uptake of hiv testing has increased in kenya men are still less likely than women to get tested and access services there is however limited understanding of the context barriers and facilitators of hiv testing among men in the country data are from indepth interviews with 30 men living with hiv and 8 hiv testing counsellors that were conducted to gain insights on motivations and drivers for hiv testing among men in the city of nairobi men were identified retroactively by examining clinical cd4 registers on early and late diagnosis eg cd4 of �500 cellsmm early diagnosis and 500 cellsmm late diagnosis analysis involved identifying broad themes and generating descriptive codes and categories timing for early testing is linked with strong social support systems and agency to test while cost of testing choice of facility to test and weak social support systems especially poor interpartner relations resulted in late testing minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives interrelated barriers at individual healthcare system and interpersonal levels hindered access to testing services specifically barriers to testing included perceived providers attitudes facility location and set up wait time inconvenient clinic times low perception of risk limited hiv knowled ge stigma discrimination and fear of having a test high risk perception severe illness awareness of partners status confidentiality quality of services and supplies flexibleextended opening hours and preand posttest counselling were facilitators experiences between early and late testers overlapped though there were minor differences in order to achieve the desired impact nationally and to attain the 909090 targets multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care

introduction the covid19 pandemic has affected at the time of writing over 200 countries with 10495019 confirmed cases and 511686 deaths various countries have reported social disparities with racial and ethnic minority groups being hit harder suffering disproportionately greater infection and mortality rates 1 covid19 mortality was markedly higher for black americans compared to all other ethnic groups 2 in wales mortality was twice as high in the most deprived compared to the least deprived areas 3 among healthcare workers in the uk two thirds of fatalities from covid19 between february and april were in black or ethnic minority workers 4 public health england published a report into the disproportionate number of cases experienced by ethnic minorities reporting that people from ethnic minorities had between 10 and 50 higher risk of death from covid19 compared to white british 5 the report suggested that the added risk was both in likelihood of exposure and in complications and mortality once infected in israel 23345 confirmed cases and 308 deaths were reported between 21st february and 25th june 2020 between march 31st and may 1st the rate of infection was 216 times higher in the lowest compared to the highest socioeconomic groups 6 minority groups in israel considered at the outset to be at greater risk due to lower socioeconomic status and higher incidence of risk factors included the arab population and the ultraorthodox jews the arab population comprises 210 of a total 91 million population of israel and the ultraorthodox community a further 101 of the population household income and participation in the workforce is lower in both these groups compared to the general jewish population housing is more crowded with 265 of arab families having more than 2 people per room compared to 46 in the general jewish population but similar to the ultraorthodox 7 although living density in ultraorthodox neighbourhoods is generally higher while housing in arab villages is more spaced out overcrowded housing was reported to be related to increased mortality from covid19 in a hospital based cohort 8 this paper presents differences in patterns of morbidity and mortality from covid19 in the arab ultraorthodox and overall populations in israel and suggests possible reasons for the low rates of infection and mortality in the arab population results in the first 4 months of israels covid19 outbreak just 2060 cases were confirmed in the arab population comprising 882 of the 23345 confirmed cases or 238 times less than would be expected relative to the population size 10 in contrast the ultraorthodox made up 3008 of confirmed cases yet just 101 of the population confirmed case rate per 100000 was twice as high in the general jewish population compared to the arab population and three times higher in the ultraorthodox population compared to the overall population rate of 308 deaths only 11 were identified as from the arab population 58 times less than expected for their population size the arab mortality rate was 057 per 100000 compared to 337 in the overall population and to 726 in the ultraorthodox community testing rates were lower in the arab population with 399 per 1000 compared to 93 per 1000 in the general population potentially identifying fewer cases however this does not explain the significantly lower mortality rate the proportion of positive tests was 274 overall 269 in the arab population and 857 in the ultra orthodox population discussion during the first wave of the covid19 pandemic in israel two population minority groups were predicted to be at highrisk the ultraorthodox fulfilled projections with a rate of infection almost 3 times higher than expected for the population segment 10 waitzberg and her colleagues described the unique cultural and behavioral norms of this sector which contributed to accelerated viral spread 11 among those norms are the tendency among some ultraorthodox communities to follow the instructions of their own religious leadership which do not necessarily coincide with governmental recommendations and the intense social and community life both resulting in the lack of physical distancing in contrast in the arab population characterized by similarly low socioeconomic status as the ultraorthodox infection and mortality rates were very low these lower rates seem to contrast with findings in other countries where ethnic minorities are at greater risk these data are surprising not only due to the ethnic minority status and weaker socioeconomic position of the arab population but also due to higher risk profile among this sector with higher incidence of risk factors and chronic illness known to increase risk of mortality for example diabetics have a 9fold increased risk of serious illness from covid 19 compared to nondiabetics 12 yet diabetes is 179 times more common in the arab compared to the jewish population in israel 13 we suggest several explanations that may account for the surprisingly low morbidity and mortality from covid19 in the israeli arab population 1 young population age is the most significant risk factor for serious illness and complications from covid 19 12 the arab population is generally younger than the jewish population with 4 aged over 65 14 though this is also true of the ultraorthodox sector with just 3 aged over 65 compared to 15 in the overall jewish population 1516 2 fewer nursing homes 45 of mortality from the virus in israel was reported in nursing homes 17 in arab society it is traditional for families to care for older members at home and less common to use outside care services 18 care homes are mostly used for short stays for rehabilitation and medical care 19 nursing homes are also far less available in arab compared with jewish localities 22 returned from abroad during the outbreak some from communities with high infection rates and indeed many of them tested positive high representation of arabs in medical professions there is a high rate of arab doctors nurses and pharmacists compared to those in the ultraorthodox population which is underrepresented in medicine and nursing 23 arabs make up 184 of nurses yet just 128 of the general workforce 24 medical teams although at higher risk of infection through exposure at work contributed to dissemination of messages in their communities regarding the reasons for and importance of following guidelines and how to maintain hygiene and social distancing this was particularly illustrated by the head of emergency medicine at a major hospital dr riad majadla who broadcast health messages in arabic on social media and radio concerning the importance of hygiene and social distancing to prevent spread of the virus including live broadcasts from areas with outbreaks and guidelines of the islamic council and continues to do so and the director of ziv medical center dr salman zarka of the druze community who posted similar messages on social media these were private initiatives that reached a wide audience 7 social media messages social networks are accessed more among the arab population compared to the ultraorthodox population who spurn use of the internet according to a survey conducted in 2017 by the israeli internet society social networks are used by 73 and 61 of the jewish and arab population respectively while 87 and 76 respectively used search engines to look for information on the internet 25 in contrast only 33 of ultraorthodox jews used the internet to look for information this wider use of social networks in the arab population allowed the broad dissemination of health messages while it has been suggested that countries with wider testing showed more confirmed cases and although testing rates were lower in the arab population this does not explain the differences in mortality seen in the arab population in israel 26 furthermore the percentage of positive tests was much higher in the ultraorthodox population compared to the general population and to the arab population in light of multiple reports from around the world of greater risk of covid19 morbidity and mortality experienced by ethnic minorities and socioeconomically disadvantaged groups it is important to understand the reasons behind lower infection rates in an ethnic minority group in a developed highincome country though the demographic makeup of israel is very different from the us and uk lessons can be learned similarities can be seen in the high burden of chronic illness found in the arab population and in the black and asian ethnic minorities in the uk and us who have higher rates of obesity cardiovascular disease and diabetes less job security and often live in more deprived and more peripheral areas it is all the more surprising then that despite these disadvantages and being overrepresented in the healthcare professions the arab community managed to avoid their predicted fate and curb the spread of the virus comparison to other countries while europe and north and south america have experienced high rates of covid19 morbidity and mortality many countries in the middle east have so far demonstrated less steep curves lockdowns were imposed early on in both jordan and lebanon where schools and mosques were closed after the first few cases appeared and strict border controls put in place 26 in contrast iran which suffered a high burden of covid19deaths did not close its mosques until a month after the first case was registered these countries share with the israeli arab population a young age demographic profile and lower use of nursing homes a much lower proportion of deaths occurred in care homes for example in jordan compared to israel and worldwide 17 in israel 2 of the overall population reside in care homeslower than many other europeanwestern countries 27 in norway the rate of covid19 infections in somali immigrants was much higher than that of the general population beyond poorer and more crowded living conditions a further explanation proposed was less access to mainstream media to counter this a campaign was targeted using youtube for public health videos in somali and a telephone hotline contributing to numbers beginning to fall in recent weeks 28 similar efforts were made in the israeli arab population to distribute health message on social media to design messages in arabic in a culturally relevant manner and recruit the support of religious and community leaders in summary based on data from the study period in the first 4 months of the covid19 outbreak the case of the israeli arab population testifies in contrast to reports from other countries that belonging to an ethnic minority or to an economically disadvantaged group does not always equate to poorer health outcomes despite a disproportionate burden of underlying illness the arab population did not fulfil initial predictions during the first wave of the covid19 outbreak and maintained low numbers of infections and deaths effective leadership and cooperation between individuals and institutions particularly engagement of community and religious leaders can reduce a groups vulnerability and build resilience in an emergency situation such as the current pandemic these strengths could be harnessed to address other health issues in ethnic minorities and specifically in the arab population in israel authors contributions mscontribution to the study design critical drafting of the whole article final approval of the submitted article accountability of all aspect of the work vmcritical drafting of the whole article final approval of the submitted article accountability of all aspect of the work rwmcontribution to the study design critical drafting of the whole article final approval of the submitted article accountability of all aspect of the work all authors read and approved the last draft of the manuscript competing interests the authors declare that they have no competing interests

background the arab ethnic minority makes up 21 of israels population yet comprised just 88 of confirmed cases and 36 of deaths from covid19 despite their higher risk profile and greater burden of underlying illness this paper presents differences in patterns of morbidity and mortality from covid19 in the arab ultraorthodox and overall populations in israel and suggests possible reasons for the low rates of infection in the arab population methods data were obtained from the israeli ministry of healths moh open covid19 database which includes information on 1270 localities and is updated daily the database contains the number of covid19 diagnostic tests performed the number of confirmed cases and deaths in israel results in the first 4 months of israels covid19 outbreak just 2060 cases were confirmed in the arab population comprising 88 of the 23345 confirmed cases or 238 times less than would be expected relative to the population size in contrast the ultraorthodox made up 301 of confirmed cases yet just 101 of the population confirmed case rate per 100000 was twice as high in the general jewish population compared to the arab population the arab mortality rate was 057 per 100000 compared to 337 in the overall population and to 726 in the ultraorthodox community we discuss possible reasons for this low morbidity and mortality including less use of nursing homes and effective leadership which led to early closure of mosques and high adherence to social distancing measures even during the month of ramadan conclusions despite a disproportionate burden of underlying illness the arab population did not fulfil initial predictions during the first wave of the covid19 outbreak and maintained low numbers of infections and deaths this contrasts with reports of increased mortality in ethnic minorities and economically disadvantaged populations in other countries and with high rates of infection in the ultraorthodox sector in israel effective leadership and cooperation between individuals and institutions particularly engagement of community and religious leaders can reduce a groups vulnerability and build resilience in an emergency situation such as the current pandemic

most of what is known empirically about travelers comes from a small number of ethnographic studies one of the first relevant studies was an investigation of service utilization patterns of homeless youth by derosa et al they interviewed a small but diverse sample of youth in the hollywood area of los angeles who had been on the streets for more than three months a subset who selfidentified as punkers indicated that they preferred to travel and that they were drawn to hollywood because of an affinity toward its street youth culture unlike other youth in this study punkers tended not to use shelters but did use other services such as dropin centers that meet immediate subsistence needs it is unclear whether the punkers in derosas study are a subset of homeless travelers or what size subset they may represent but their demographic and stylistic features fit both with characterizations of travelers in the popular press and with the descriptions of travelers provided by others hyde interviewed 50 homeless youth in los angeles to understand the circumstances surrounding their departure from home nearly a quarter of these youth drawn from social service agencies and outdoor areas of los angeles claimed that they left home because they wanted to travel and experience new opportunities often selflabeling as travelers these youth alternately expressed their enthusiasm ambivalence and disillusion with living on the streets and moving from place to place additional insights come from a study of 213 young injection drug users recruited from the streets of los angeles new orleans and new york city of whom 62 were identified as homeless travelers based on questions about housing status and history of homelessness these youth did not remain in a city for longer than a month and reported regularly moving to towns and cities outside the recruitment area ethnographers notes described style attributes that make travelers easily distinguishable from local homeless youth including unique hairstyles visible tattoos numerous facial and body piercings and military or punkstyle clothing travelers were largely white male and heterosexual in their early twenties and drug users because no data were presented on local homeless youth however the degree to which these travelers differ from other homeless youth is uncertain finally a study of urban nomads in new york city interviewed 139 homeless youth who had traveled to at least three different cities in the past year high levels of drug use were observed however similar to the work of lankenau and sanders the recruitment criteria included recent illicit drug use and no comparison data were presented on local homeless youth although these ethnographic studies provide a rich picture of traveling homeless youth suggesting unique stylistic features heavy substance use and distinct service use preferences it is difficult to generalize from them given their convenience samples select recruitment criteria and lack of comparison groups a recent study avoided some of these limitations by comparing homeless youth with different levels of transience on measures of drug abuse and dependence youth with moderate and high levels of transience were marginally less likely to exhibit drug abuse and dependence than were youth with low levels of transience these findings are at odds with the studies of homeless youth previously described as well as studies of homeless adults showing that transience is positively associated with risky sexual behavior hiv risk behavior and depression ferguson et al caution readers about drawing conclusions about the link between transience and substance use from their study given its focus on abuse and dependence rather than use per se and considering that their data came from small convenience samples of homeless youth thus although this study improves upon prior research on travelers by incorporating a comparison sample of nontraveling homeless youth it leaves open the questions of whether homeless travelers have a greater inclination towards risky behavior and if so why more research is therefore required to understand the characteristics and needs of homeless travelers especially needed is research that compares representative samples of homeless travelers and nontravelers on a range of risky behaviors known to be prevalent among the general population of homeless youth including high risk drug use and risky sexual behavior such comparisons should control for demographic characteristics that are likely to confound associations between traveler status and risky behavior also needed are efforts to identify factors that explain differences in risky behavior between traveling and nontraveling homeless youth one explanation may lie in the social networks of these youth social networks are crucial determinants of a range of risktaking behaviors among homeless youth including drug and alcohol use unprotected sex and other hiv risktaking behaviors typically research on homeless youth has focused on the problematic influence of peers on risktaking behaviors with little attention given to positive impacts of social support or affiliation with prosocial peers the risk amplification model provides one explanation for the problematic influence of peers on risk behaviors of homeless youth arguing that when youth leave home they are derailed from typical adolescent developmental pathways and become increasingly imbedded in social networks dominated by problematic peers affiliation with these problematic youth provides modeling of and reinforcement for risktaking and deviant behaviors although the social networks of homeless youth are often presumed to be comprised primarily of other homeless youth in similar circumstances recent work suggests that this is not necessarily the case rice et al for example found that 73 of their sample of newly homeless youth in los angeles claimed that most or all of their friends attended school regularly and 24 claimed most or all of their friends had jobs moreover the presence of such individuals predicted less hiv sex risk behavior and drug use and less antisocial behavior these and other studies suggest that the presence of prosocial peers in the networks of homeless youth may serve a protective role by discouraging risky practices the presence of family members in homeless youths social networks also may have implications for risktaking behavior although homeless youth by definition have disrupted family relationships many maintain ties to family members even once they are out of the home social control theory which suggests that bonds to conventional others may have a constraining effect on risky and antisocial behavior suggests that the presence of family members in ones social network may inhibit substance use and risky sexual behavior however because many homeless youth have fled abusive family circumstances where parental deviance including substance use is common maintaining family ties may be more hurtful than helpful characteristics of homelessness and engagement in street life are known to impact the composition of homeless youths social networks for example it is well established that as youth spend more time on the streets their engagement with nontraditional and highrisk peers increases traveler status may likewise impact youths engagement with nontraditional and highrisk individuals transience apart from homelessness is associated with having less supportive networks and fewer connections to prosocial potentially stabilizing influences given their increased transience it may be that homeless travelers compared with nontravelers have fewer connections to family and other stabilizing influences and greater connections to problematic peers who model and reinforce risky behavior such differences in the social networks of travelers and nontravelers may contribute to differences in risky behavior between the two groups however increased mobility may not necessarily impede travelers from maintaining prosocial stabilizing influences like homebased peers and family members recent research has shown that the majority of homeless youth maintain their relationships with family and homebased peers through use of the internet especially email and social networking technologies in a recent survey of homeless youth in los angeles rice et al found that 84 of their sample accessed the internet at least weekly typically at libraries and youth service agencies almost half of those who access the internet regularly reported use of email and social networking websites to communicate with family members and friends from home thus although there is reason to believe that travelers as a function of their transience may have fewer connections to prosocial stabilizing influences this is not necessarily the case as travelers may maintain such connections via the internet current study the primary goal of our study was to compare young homeless travelers with nontravelers on demographic and homelessness characteristics service utilization substance use and risky sexual behavior secondarily we explored whether differences in the composition of travelers and nontravelers social networks may account for differences in their substance use and risky sexual behavior because of their transience we expected travelers to have fewer family ties than nontravelers a lower likelihood of being employed or in school and fewer ties to individuals who are employed or in school we expected that travelers would report being in their current location for a shorter time and that they would therefore report a greater percentage of homeless individuals as network members finally we expected that travelers would exhibit more substance use and risky sexual behavior than nontravelers and that this difference in behavior would be associated with differences in the composition of their social networks methods study design we recruited a probability sample of homeless youth from shelters dropin centers and street venues in los angeles county between october 2008 and august 2009 because a list or sampling frame of all the homeless youth in the study area is not available we adopted a multistage design the first stage involved the selection of sites we developed two sampling frames one for the shelters and dropins and one for the street venues the first sampling frame was developed using local directories of services for homeless persons service sites were considered eligible if they were located in the study area and the majority of their clientele was ages 13 to 24 and english speaking service sites not limited to that age group were eligible if they had a specific program geared toward youth for shortterm transitional housing programs the average length of stay had to be at most one year our final list of service sites consisted of 15 shelters and seven dropin centers the second sampling frame was developed with the help of service providers and outreach agencies the research team identified 19 street sites in the study area where homeless youth congregate all sites were investigated multiple times and at various times of day to obtain an estimate of the average number of youth served daily by the service sites and the average number of youth that hang out at the street venues in a given day information collected through site investigations was used to assign a quota for the number of completed interviews to be achieved at each site which was approximately proportional to the size of a site the second stage of the sampling design consisted of drawing a probability sample of homeless youth from the 41 study sites strategies specific to the type of site were developed to randomly select the youths to be approached screened and interviewed study participants and procedures study participants were 419 homeless youth in los angeles county between the ages of 13 and 24 years who were randomly sampled from the 41 shelters dropin centers and street sites described above youth were eligible if they were between the ages of 1324 were not currently living with a parent or guardian were not getting significant support for food and housing from family or a guardian spent the previous night in a shelter outdoor or public place hotel or motel room rented with friends or other place not intended as a domicile and were english speaking of the 446 youth who screened eligible for the study 437 were interviewed and 18 of these were later found to be ineligible and excluded computerassisted structured interviews lasting 60 minutes on average were conducted by trained interviewers youth received 25 for their participation this research was approved by rands institutional review board and a certificate of confidentiality was obtained from the us department of health and human services measures traveler statusno standard method exists for defining a young homeless traveler they have been variously defined as youth who traveled to at least 3 cities in the past year youth who did not remain in a city for more than a few weeks or a month and who reported regularly moving to different towns or cities and youth who made multiple moves since initially leaving home in our study we defined travelers as homeless youth who had lived in at least two states besides california with at least one of those states being a nonneighboring state to california with this definition we hoped to capture homeless youth who had traveled extensively over significant distances in the united states demographic characteristicsthese characteristics included age gender sexual orientation race and ethnicity income from all sources in the past 30 days as well as whether the youth had a high school diploma or ged attended school regularly in the past year and was currently employed either fullor parttime homelessness characteristicsyouth reported the age at which they first left home and their main reason for doing so for the latter youth provided openended responses that we coded into one of five categories family conflict or problems desire to be on ones own family or housing instability emancipated aged out of foster care and a residual category that included responses that did not fit clearly into another category youth reported whether since leaving home the first time they had returned to living with a parent or guardian youth who had returned to living with a parent or guardian were asked to report the age at which they left home the last time for these youth we calculated length of time homeless by subtracting their age at the time they last left home from their age at the time of the survey for youth who had not returned to living with a parent or guardian we calculated length of time homeless by subtracting their age at the time they first left home from their age at the time of the survey youth reported which areas of california they had stayed in since last leaving home and which states besides california they had stayed in finally youth reported whether in the past 30 days they had spent a night in any of the following places because they had nowhere else to stay social network characteristicswe used established procedures to assess characteristics of youths social networks we asked respondents to provide the first names of 20 individuals aged 13 or older that they knew who knew them and with whom they had contact during the past 3 months contact with alters could be facetoface by phone or mail or via the internet we constrained network size to be the same across respondents to maximize comparability of network characteristics across respondents twenty alters has been shown to capture structural and compositional variability present in personal networks we then asked about each alters behavior and relationship to the respondent we classified alters into the following mutually exclusive categories relatives or guardians nonrelative sex partners adults in position of responsibility and all others who did not fit these categories for each alters we asked whether the individual was regularly in school or employed and whether the individual was homeless in the past 3 months finally we asked respondents to identify which alters they believe drank alcohol to the point of drunkenness in the past 3 months used drugs in the past 3 months and engaged in risky sexual behavior in the past 3 months substance usewe assessed heavy alcohol marijuana and other drug use for a 30day period with items from the youth risk behavior survey heavy alcohol use was defined as having 5 or more drinks of alcohol in a row in addition to heavy alcohol and marijuana use youth reported on their use of each of the following substances crack cocaine heroin ecstasy hallucinogens and prescription drugs or overthecounter medications to get high finally youth reported whether they had used a needle to inject any illegal drug using these data we computed indices of current heavy alcohol use marijuana use other drug use and injection drug use sexual behaviorwe calculated the number of sexual partners in the past 3 months by summing the number of different male and female partners that youth reported we calculated the percentage of sexual events that were condomprotected by dividing the number of times a youth reported using condoms during intercourse by the total number of times the youth reported having sexual intercourse in the past 3 months during the social network assessment we asked whether each alter identified as a sexual partner was a spouse boyfriend or girlfriend casual partner or a needbased partner we also asked youth to report for up to four alters who were recent sex partners whether they and the alter used alcohol or drugs before or during sex in the past 3 months from this information we computed dichotomous indices of having any casual or needbased sexual partner in the past 3 months and using alcohol or drugs prior to sex in the past 3 months statistical analysis we developed and used sampling weights to correct for deviations from proportionatetosize random sampling due to changes in the sampling rates during the fielding period differential nonresponse rates across sites and differential rates of visits to shelters dropins and street sites all analyses incorporate these weights and account for the modest design effect that they induce using the linearization method we first used ttests and chisquare tests to compare travelers and nontravelers on demographic and homelessness characteristics service use social network characteristics substance use and risky sexual behavior next we estimated bivariate associations between each of the social network characteristics and both substance use and risky sexual behavior finally we conducted multivariable analyses of substance use and sexual behavior variables on which travelers and nontravelers differed at the bivariate level we performed logistic regressions to model multivariable associations between traveler status and our dichotomous measures of substance use and risky sexual behavior we used negative binomial regression analysis to model the multivariable association between traveler status and count variables such as number of sexual partners we present adjusted odds ratios for the logistic regression analyses and adjusted incidence rate ratios for the negative binomial regression analyses predictor variables were entered into the regression models in two steps first we entered traveler status and demographic characteristics found to differ between travelers and nontravelers in the bivariate analyses this allowed us to determine whether bivariate associations between traveler status and substance use or risky sexual behavior were due simply to confounding of traveler status and demographic characteristics we also added length of homelessness at this first step as this variable is known to be associated with levels of risk behavior among homeless youth and is also likely to be associated with traveler status at the second step we added social network characteristics that we hypothesized as potential mediators of the association between traveler status and risky behavior ie absence of ties to individuals in conventional roles and presence of ties to peers engaged in relevant risky behaviors however we only added these hypothesized mediator variables to the model if we found them to be associated with traveler status at the bivariate level of analysis evidence of mediation would be present if the dependent variable was significantly associated with traveler status at the first modeling step traveler status significantly predicted the mediating variable controlling or demographics and weeks homeless and the association between traveler status and the dependent variable were significantly reduced when the mediators were entered into the model results bivariate comparison of travelers and nontravelers on background characteristics as expected travelers were more likely than nontravelers to be older male and white and less likely to be african american or hispanic travelers were more likely to have a high school diplomaged and less likely to have attended school in the past year sexual orientation employment status and income did not differ between the two groups bivariate comparison of travelers and nontravelers on housing history and service use as table 2 shows travelers left home for the first time at a younger age than nontravelers and were more likely to report a desire to be on their own and less likely to report family conflict or problems as the main impetus for leaving home travelers and nontravelers were just as likely to have returned home to live with their parents after having left home initially but the length of time since last leaving home was considerably greater among travelers than among nontravelers consistent with their transient lifestyles travelers had stayed in their current location for approximately half as long as nontravelers and had stayed in more areas of california as well as more states outside california travelers were more likely than nontravelers to report spending the night outdoors in a motor vehicle in a backyard or storage structure or in an abandoned building travelers were less likely than nontravelers however to have spent the night at an emergency shelter or in transitional housing finally travelers were more likely than nontravelers to have recently visited a dropin or access center and used a food pantry or meal line and less likely to have recently used alcohol or drug counseling bivariate comparison of travelers and nontravelers on social network characteristics compared with nontravelers travelers reported social networks comprised of fewer relatives and people who were employed or in school but more people who were homeless travelers networks also included more individuals perceived to engage in heavy alcohol use drug use and risky sexual behavior travelers and nontravelers did not differ however on the percentage of their network members who were sex partners bivariate comparison of travelers and nontravelers on substance use and risky sexual behavior as table 4 indicates travelers consistently exhibited more substance use than nontravelers travelers were almost twice as likely as nontravelers to exhibit heavy drinking in the past month 37 more likely to have used marijuana 70 more likely to have used other drugs and five times as likely to have injected drugs differences between travelers and nontravelers on risky sexual behavior were in the expected direction but only two associations were statistically significant travelers had more sex partners in the past three months than did nontravelers they were also more likely to combine alcohol andor drug use with sex in the past three months travelers and nontravelers did not differ in their condom use or in the likelihood of having had casual or needbased sexual partners bivariate associations between social network variables and substance use and risky sexual behavior table 5 shows bivariate associations between each of the social network characteristics that differed between travelers and nontravelers and each indicator of substance use and risky sexual behavior that differed between travelers and nontravelers mean comparisons are presented for the dichotomous substance use variables for example we show the mean percentage of family members in ones social network among participants who did and did not exhibit current heavy alcohol use correlation coefficients are shown for associations involving number of sex partners as this table shows there were consistent and typically strong associations between social network characteristics and risky behavior moreover all associations were in the predicted direction in particular participants engaged in versus not engaged in current heavy alcohol use marijuana use injection and other drug use and who used versus did not use substances prior to sex had social networks comprised of fewer family members fewer individuals in school fewer employed individuals more people who were homeless and greater percentages of heavy alcohol users drug users and individuals thought to engage in risky sexual behavior likewise number of sex partners was positively associated with the percentage of network members who were homeless heavy alcohol users drug users and engaged in risky sexual behavior and negatively associated with the percentage of network members who were family members and students multivariable models predicting substance use as table 6 shows all associations between substance use and traveler status remained after controlling for demographics and length of homelessness the only social network variable that significantly predicted current heavy alcohol use in the final multivariable model was the percentage of alcohol users in ones social network a separate multivariable regression analysis that controlled for demographics and length of time homeless showed traveler status to be a reliable predictor of the percentage of alcohol users in ones social network baron and kenny provide a direct test of whether the reduction of an association due to a hypothetical mediator is statistically significant using this test we found that the reduction in the association between traveler status and current heavy alcohol use due to the percentage of alcohol users in ones social network is statistically significant the only social network variable that significantly predicted current marijuana use in the final multivariate model was the percentage of drug users in ones social network a separate multivariable regression analysis that controlled for demographics and length of time homeless showed traveler status to be a reliable predictor of the percentage of drug users in ones social network using baron and kennys test of mediation we found that the reduction in the association between traveler status and current marijuana use due to the percentage of drug users in ones social network is statistically significant in the final multivariable model of current use of other drugs the percentage of students employed individuals alcohol users and drug users in ones social network were all significant predictors each of these social network characteristics was reliably predicted by traveler status predicting percent of employed individuals b 060 se 029 p 04 predicting percentage alcohol users b 129 se 042 p 0002 predicting percentage drug users b 215 se 042 p 001 a joint test of significance showed that jointly these hypothetical mediators explained a significant amount of the association between traveler status and current other drug use in the final multivariable model of current injection drug use the percentage of family members homeless individuals and alcohol users in ones social network were all significant predictors only the percentage of homeless individuals and alcohol users were reliably predicted by traveler status together these variables explained a significant amount of the association between traveler status and current injection drug use multivariable models predicting sexual behavior table 7 shows that the association between traveler status and number of sex partners was eliminated once demographic differences and length of time homeless were taken into account in particular the bivariate association between traveler status and number of sex partners seems to have been due to hispanics lower likelihood of being travelers and their inclination to have fewer sex partners finally table 6 shows that the association between traveler status and the likelihood of using alcohol or drugs prior to sex remained after controlling for demographic factors but was accounted for by the percentage of students and the percentage of alcohol users in ones social network discussion evidence of the heterogeneity of homeless youth across the united states is mounting studies suggest that homeless youth tend to identify with one or more subgroups of homeless youth and that their service needs may be driven in part by subgroup membership our study adds to this literature by focusing on travelers a migratory population of homeless youth that has received little empirical attention although the size of this subpopulation is unknown our study suggests that it may comprise as many as a quarter of homeless youth in cities that are established stopping points for homeless travelers such as los angeles both travelers and nontravelers most commonly mentioned family conflict or problems as the main reason why they left home the first time however compared to nontravelers the travelers left home for the first time at a younger age and they did so less often because of family conflict and more often out of a desire to be on their own the notion that most travelers are primarily driven to leave home by a desire for independence is overly simplistic nonetheless results from both this study and qualitative data presented by hyde suggest that travelers may be more likely than other homeless youth to view their homelessness as an adventure to some extent at least at first although travelers and nontravelers face many of the same challenges in living on their own the travelers in our sample were less likely to access certain services that could help them stabilize their lives travelers were much more likely to report spending the night in risky places and much less likely to report staying in shelters or transitional housing though this may reflect their desire for geographic mobility it may also be the case that traditional homeless youth services and programs hold less appeal for travelers who are distinct from other homeless youth in terms of demographics behavior and appearance travelers may be more likely to bristle at the strict rules and regulations often imposed by shelter providers or may simply feel that they do not fit in at these settings travelers were also less likely than nontravelers to obtain substance use counseling despite their significantly higher rates of use just as studies have identified barriers to care among homeless youth in general it is important to understand better such barriers among travelers as it may be necessary to target services specifically to the unique needs and preferences of this population a key aim of this study was to compare the social networks of travelers and nontravelers to understand travelers increased involvement in risk behavior travelers were more likely than nontravelers to be connected to similarly unconventional individuals exhibiting risky behaviors and less likely to have conventional social ties such as to family members students and stably employed individuals our results suggest that some of these differences in network composition are important in that they relate to the considerable differences between travelers and nontravelers in injection drug use and other forms of substance use that were found in this study and have been reported by others if these relationships can be shown to be causal then alcohol and drug prevention programs that focus on the individual will be less effective than ones that also help youth to establish and strengthen conventional social ties while also minimizing the negative impact of associating with highrisk peers although in most of the multivariable models only one or two social network variables emerged as significant predictors of youths behavior all of the social network characteristics were linked to risky behavior in the bivariate models and always in the predicted direction typically the social network characteristics that emerged as significant predictors in the multivariable models were ones clearly relevant to the dependent variable for example heavy alcohol use was associated with the percentage of heavy alcohol users in ones network and the number of sex partners was associated with the percentage of network members perceived to engage in risky sexual behavior these findings are consistent with the notion of peer modeling and reinforcement of risky behavior among homeless youth however we also uncovered in our multivariable models associations that are consistent with the notion that connections to individuals engaged in conventional roles may constrain homeless youths engagement in risky behavior for example we found that youth with networks that included more individuals who are employed and in school had a lower likelihood of using drugs other than marijuana given the degree of correlation among the network variables it is not surprising that only some emerged as significant predictors in the multivariable models that these network variables fully account for the differences in risky behaviors between travelers and nontravelers adds greatly to what is known about homeless travelers and their increased proclivity toward risky behavior and is compatible with prior studies of how social network characteristics are associated with risky behavior in this population we note a few anomalous associations that emerged in the multivariable models youth with more family in their network were more likely to inject drugs those with more employed individuals in their network had more sex partners and those with less time homeless were more likely to engage in substance use since these associations emerged only after youth were equalized on a variety of social network characteristics they should be interpreted with caution our study has several limitations that must be considered when interpreting its results first our results may not generalize beyond the population of homeless youth living in los angeles county almost all of what is known about travelers is based on data from youth recruited in los angeles and new york city thus there is a clear need for data that is more widely representative of the u s homeless youth population second the crosssectional design makes it impossible to tease apart selection versus social learning processes although both are likely to operate among homeless youth neither can we rule out that affiliation with unconventional peers leads youth to adopt a transient lifestyle or that substance use differences between travelers and nontravelers are not due to differences in their proclivities toward risk or tendencies to be sensationseeking rather than social network influences finally although our operational definition of traveler status resembles that of others who have studied this population and clearly distinguishes travelers from nontravelers on characteristics known to vary between these two groups it is nonetheless a logical definition rather than one based on selfdefinition by homeless youth our study extends prior research by investigating a more representative sample of homeless travelers and comparing them to nontravelers from the same locations investigating a wider range of risky behaviors and attempting to provide clues about the source of travelers elevated risk although more research is needed to understand the processes that drive homeless traveling youths elevated substance use our research suggests that the risk is potentially attributable to their deviant peer associations and disconnection to conventional institutions and individuals our research also suggests that despite high levels of substance use and risky sexual behavior travelers are less likely to access certain services and programs targeting these behaviors in some cases the issue is lack of availability for example homeless youth services in los angeles county are concentrated primarily in hollywood but travelers are less likely to be found in hollywood than other areas of the county in addition to access issues travelers may be resistant to seeking services if they do not perceive a need for them or if the available services are not appealing it may be necessary to better market homeless services to travelers so that they feel less compelled to quickly establish ties with other highrisk travelers when they arrive in a new city in order to meet their basic needs for survival finally because travelers are on the move interventions may need to be shorter and less traditional greater integration of services would likely also be beneficial so that when they are ready for help the first service door travelers enter can connect them to multiple services a odds ratios for social network characteristics have been adjusted so that they correspond to increments of 10 percentage points this adjustment has no effect on the statistical significance of the odds ratio b odds ratio for nonhispanic whites compared with all others we were not able to further differentiate between racialethnic groups as we did in all other models because there was little reported injection drug use in groups other than nonhispanic whites a odds ratios for social network characteristics have been adjusted so that they correspond to increments of 10 percentage points this adjustment has no effect on the statistical significance of the odds ratio

travelers are a migratory subgroup of homeless youth who may be especially prone to engaging in risky behavior this study compared the substance use and sexual behavior of young homeless travelers and nontravelers to evaluate the extent and possible sources of travelers increased risk data came from facetoface interviews with 419 homeless youth 366 female 340 white 239 african american and 200 hispanic between the ages of 13 and 24 years m 201 years sd 25 who were randomly sampled from 41 shelters dropin centers and street sites in los angeles travelers were almost twice as likely as nontravelers to exhibit recent heavy drinking 37 more likely to exhibit recent marijuana use and five times as likely to have injected drugs travelers also had more recent sex partners and were more likely to report having casual or needbased sexual partners and combining sex with substance use mediation analyses suggest that travelers deviant peer associations and disconnection to conventional individuals and institutions may drive their elevated substance use differences in sexual risk behaviors are likely attributable to demographic differences between the two groups overall these differences between travelers and nontravelers suggest different service needs and the need for different service approaches

introduction stress can be a physical mental andor emotional response to lifes changes and demands stress can have immediate and chronic effects the stress response is the set of physical and emotional changes the human body makes in response to a threat or stress 1 stress has been linked to chronic disease because if it occurs too often or lasts too long the immune system can be weakened making it harder to fight off disease andor worsening existent health problems thus stress is a particularly important issue for lupus patients since lupus is an autoimmune disease wherein the immune system is already dysfunctionally attacking the bodys own cells lupus patients are advised to avoid stress and to try to lead lives that are close to normal because physical or emotional stress can trigger an exacerbation and affect overall physical health 2 3 4 it has been suggested that social support or the extent to which resources in the social environment meet an individuals interpersonal needs has a positive influence on health status social support has gained much research attention due to its believed beneficial effects on the psychosocial and physical wellbeing of lupus patients 5 6 7 8 9 10 some researchers have examined both stress and social support and their effects on the mental and physical health of sle patients but not their relation to each other dobkin and associates 11 assessed daily hassles social support psychologic distress and quality of life in 44 women with sle using standardized instruments and found that high stress and poor social support were the strongest predictors of patients perceived global physical health and psychologic distress other variables investigated included sle disease activity and damage age disease duration education and ethnicity 11 in addition to life stress and social support kozora et al 12 examined coping styles in relation to psychological processes in sle and rheumatoid arthritis patients investigators measured depression mood disease activity perceived health and cognitive ability and found that increased depressive symptoms and distressed mood state in sle patients were related to use of disengaging and emotional coping styles 12 dobkin and colleagues 13 assessed psychological distress social support stress coping and healthrelated quality of life they observed that better physical health was predicted by more emotionoriented coping in patients in a more active disease state suggesting that this style of coping may be more adaptive in situations that are considered uncontrollable 13 mccracken and associates 14 investigated the relations of coping with psychological adjustment and functional status in 46 adults with sle and found that seeking social support was a significant predictor of adjustment although neither perceived nor tangible social support was measured in relation to coping 14 while the effects of stress and social support on disease activity in lupus patients have been welldocumented there is lack of information in the literature on the association between social support and stress levels among lupus patients therefore the objective of this study was to determine if there is a link between social support and selfreported stress and coping status among african american women with lupus patients and methods in brief this paper reflects the analysis stresscoping and social support data collected from two linked crosssectional surveys cases analyzed for the current study were participants in the buffalo lupus project and breakfast with a buddy biomarkers of lupus study the buffalo lupus project a partnership between the toxic waste lupus coalition and the university at buffalo was formed to count the number of people in the buffalo community who had lupus and other autoimmune diseases and also to uncover any common factors that may elucidate the complex causes of lupus and other autoimmune diseases at its onset the buffalo lupus project consisted of a registry and survey the survey component of the buffalo lupus project focused on the east side of the city of buffalo ny which is predominantly african american these areas were targeted due to citizens concern about high rates of autoimmune disease in the area that they believed may be related to the presence of a toxic waste site there trained interviewers completed surveys with 66 patients with sle 52 of whom were african american women survey topics included demographics diagnosis health care utilization residential history residential history exposure occupational history occupational history exposure smoking history family health history and social support upon completion of the survey each participant was invited to participate in the breakfast with a buddy biomarkers of lupus study which was developed to investigate the relationship between inflammation and heart disease in african american women with lupus participation in the study included a fasting blood draw carotid ultrasound physical measurements and a short questionnaire assessing traditional cardiovascular risk factors including stresscoping status currently 317 residents with lupus and other autoimmune diseases have registered with the buffalo lupus project out of the 317 current registrants 194 have reported being diagnosed with sle and of those sle cases 92 were eligible to participate in the buffalo lupus project survey due to having ever lived or currently living in zip codes 14211 or 14215 sixtysix sle cases completed the survey and all were invited to participate in the biomarkers study 44 consented corresponding to a 67 percent response rate responses to the social support variables from the buffalo lupus project survey were merged with the breakfast with a buddy biomarkers of lupus study database and those cases who had participated in both projects and responded to both social support and stress questions were selected out for analysis fortythree cases had available values for both stress and social support inquiries after exclusion of those cases with do not knownot applicable responses for the dichotomized stresscoping variable 41 cases were included in analysis stress and coping status was measured as selfreported perceived level of stress and ability to cope using a question adapted from the american heart association coronary risk assessment questionnaire 15 which asked the participants to describe how they currently coped with stress in their life using a fiveitem scale responses were dichotomized for analysis specifically seldom and sometimes responses were coded as nolow stress and often heavily and excessively responses were codes as yeshigh stress social support was assessed by six questions adapted from the social support questionnaire 6 and medical outcomes study short form health survey 6 16 17 18 19 20 21 five themes were evaluated perception of having a support system and individualsgroups comprising it proximity and number of perceived close friends and family members perception of having someone there to take over tasks and chores if sick membership and attendance at faith based and other types of meetings and frequency of gettogethers and conversations with friends relatives and neighbors participants were asked how many close friends or relatives they saw at least one time per month how many times in a typical week participants talk on the phone and how often patients get together with friends or relatives participants were also asked if they had a support system if they lived with someone they considered to be a close friend or relative and if they belonged to any clubs andor organizations confounding variables assessed included age highest level of education attained annual household income smoking status and race the stresscoping variable was crosstabulated with each of the six social support variables investigated using spss and percentages were calculated statistical tests were conducted based on the fisher exact test and 𝑡test due to the 𝑁 total number of participants 𝑛 number of participants in each cell percent and sd standard deviation small sample size by assuming the independence among the high and low stress group results approximately 88 percent of participants were african american and the remaining 12 percent were caucasian the mean age of participants was 508 years less than ten percent of participants completed less than 12 years of school approximately 77 percent of participants graduated from high school and 17 percent attained a college degree or higher table 1 shows that 28 participants were classified as nolow stress the remaining 13 participants were classified as yeshigh stress when divided into categories of low and high stress those reporting higher levels of stress were slightly younger than those in the nolow stress category there were more white participants in the yeshigh stress category than there were in the nolow stress category conversely there were more black participants in the nolow stress category than there were in the yeshigh stress category in both categories the majority of participants reported attending some college or attaining a college degree or higher in the yeshigh stress category the majority of respondents reported annual household incomes below 3000000 conversely in the nolow stress category the most respondents reported annual household incomes at or above 3000000 in both stress categories few participants reported being current smokers table 2 shows that most of the sle patients in the current study had a support system that was comprised of both immediate family members and unrelated sources of support while the majority of participants in both stress categories reported their family children siblings other family members and friends to be part of their support systems more participants in the yeshigh stress category reported their spouse and a spiritual leader to be part of their support system compared to participants classified as nolow stress additionally approximately half of participants in the nolow stress category reported coworkers to be a part of their support system while less than a quarter of participants in the yeshigh stress category reported coworkers to be a part of their support system more than half of participants reported living with someone they considered a close friend or relative and the majority of participants reported belonging to at least one club or organization few differences were observed between the two stress categories with respect to the six social support variables investigated in both categories the majority of participants reported having four or more close friends andor relatives they see at least once per month and talking on the phone with family friends andor neighbors more than once per week the largest number of participants in both of the stresscoping categories reported getting together with friends andor relatives one to three times per month or once per week or more however a smaller percentage of participants in the nolow stress category reported getting together with friends andor relatives one to three times per month when compared with participants in the yeshigh stress category 32 percent of the nolow stress group and 54 percent of 𝑁 total number of participants 𝑛 number of participants in each cell percent and sd standard deviation the yeshigh stress group and a smaller percentage of participants in the yeshigh stress category reported getting together with friends andor relatives once per week or more when compared with participants in the nolow stress category in both categories the majority of participants perceived themselves to have a support system and live with someone they consider a close friend andor relative the same trend was observed with respect to cluborganization membership in both categories the majority of participants reported belonging to a club or organization although a smaller percentage of participants in the nolow stress category reported this trend when compared with participants in the yeshigh stress category discussion the current study did not observe social support differences in groups of high and low stresscoping from a predominantly african american sample of middleaged women with sle a key finding indicates that most sle patients in the current study had social support there are a variety of reasons where a link between higher levels of social support and lower levels of stress was not observed there may in fact not be a relationship between the two factors however statistical tests were not conducted due to small overall sample size and inability to compare such small groups as independent samples when divided into groups of high and low stress it will require a duplicate study with a larger sample size to determine if findings are reproducible and statistically valid it is more likely that the homogeneity of the study sample made it impossible to observe existent trends in addition to very little variability with regard to social support there was very little variability in the sample with regard to race and education however the slight differences in age race andor income between the two stress categories could have masked the effects of social support it is also possible that the way social support and stresscoping were assessed was not comprehensive enough and therefore did not truly measure what the present study aimed to measure other studies of stress and coping in sle populations used entire scales such as the daily stress inventory and daily hassles questionnaire 4 22 23 24 25 26 whereas the current study assessed stress and coping using one question although the question incorporates response choices reminiscent of such validated scales the scales used may not have been appropriate since participants usually want to report what they think the interviewer wants to hear misclassification may have occurred due to such response bias since other studies have not examined stress and social support in relation to one another present results could not be compared to those of other investigators it was assumed however that a positive relationship between stress and social support would be observed similar to the positive relationships between social support and physical wellbeing of lupus patients observed by other researchers 5 6 7 8 9 10 it cannot be ignored however that social support is one of the most important factors in predicting the physical health and wellbeing of everyone ranging from childhood to older adults the absence of social support shows some disadvantage among the impacted individuals in most cases it can predict the deterioration of physical and mental health among the victims the initial social support given is also a determining factor in successfully overcoming life stress studies in the general population have observed that the presence of social support significantly predicts the individuals ability to cope with stress knowing that they are valued by others is an important psychological factor in helping them to forget the negative aspects of their lives and think more positively about their environment not only does social support help improve a persons wellbeing it affects the immune system as well thus it is also a major factor in preventing negative symptoms such as depression and anxiety from developing 27 while the present study did not observe differences in an sle cohort broken into groups of high and low stress with respect to amount of social support perceived it is an area that should be explored further health status and disease activity in patients with sle and other chronic diseases are strongly associated with social support which suggests that enhanced social support in medical care might improve sle outcome conflict of interests the authors have no conflict of interests or financial ties to disclose submit your manuscripts at stem cells international hindawi

lupus patients should avoid stress because physical or emotional stress can affect overall physical health it has been suggested that social support has a positive influence on health status but there is a lack of information in the literature on the association between the two among lupus patients the current study investigated the association between social support and selfreported stress and coping status among african american women with lupus using data collected from two linked crosssectional surveys no social support differences in groups of high and low stresscoping were revealed a duplicate study with a larger sample size is required

but when you leave your family and you feeling its maybe dangerous you are feeling you are not here you are here but you are not here you are safe but you are there rania rania is from deir ezzor in eastern syria she hopes that soon she and her toddler son can join her husband in germany although she has not yet had an asylum interview to discuss her resettlement options 1 every day she waits for a phone call from the asylum office in athens and she frequently contacts her lawyer to see whether there are updates on her case in order to overcome the negative feelings that accrue from living apart from her loved ones rania regularly talks with her family over the phone for rania and refugees 2 like her having access to a smartphone is essential for negotiating the anxieties and ambivalences produced through protracted experiences of waiting yet literature on media and migration rarely addresses the affective entanglements of migrant digital practices while recent scholarship has zoomed in on migrant smartphone use narratives tend to focus on migration journeys and often centre the experiences of men however such a focus on digital journeys reinforces gendered binaries of activepassive moving waiting where men are the ones who move and women are the ones left behind in an effort to trouble gendered binaries this article explores the ways refugee women demonstrate agency while waiting to travel onwards my aim is neither to romanticise nor exceptionalise womens experiences of waiting rather i argue that it is necessary to consider the types of mobilities that are possible and may be engaged while waiting i am particularly interested in ordinary mundane practices everyday actions which allow individuals to persevere i choose to explore affective digital practices because like emotions smartphone use is highly gendered taking the cultural politics of emotion as an entry point this article uses the dialectic of strategy and tactics to explore refugee womens digital practices as tactical interventions in the regime of waiting specifically the ways in which smartphones are mobilised in order to make do with protracted experiences of displacement in my argumentation i draw from 15 distinctly situated affective and embodied accounts gathered at a refugee camp in mainland greece this feminist research project centres a reflexive and vulnerable methodology meaning i aim to make generative how questions of ethics power and positionality are negotiated in the field and may be represented more justly in the writing and textual analysis of that fieldwork this article is structured as follows first i connect feminist affect theory to studies of migrant digital practices i then discuss intersectional analyses of space and time in an effort to move beyond spatial descriptions of displacement and to politicise the representation of refugee temporalities as liminal conditions i conclude the theoretical section with an explanation of how mediated practices of making do constitute particular forms of agency next i discuss the fieldwork contexts which includes reflection upon my own positioning as well as my understanding and practice of a reflexive vulnerable methodology in the first empirical section i explore nonmainstream news consumption as a tactic of selfcare whereby refugees forego mainstream news media in favour of news shared by their personal networks the second empirical section explores mediated family practices as a tactic of hope which serves to hopefully orient refugees towards the future the final empirical section explores nature photography as a tactic of creativity whereby youth draw upon the smartphones affordances in order to engage in emotive mobilities as will become evident in this article affect is the red thread that guides this project smartphones as affective and embodied objects ‫علينا‬ ‫يطمئن‬ ‫و‬ ‫عليه‬ ‫أطمئن‬ ‫زوجي‬ ‫مع‬ ‫احكي‬ ‫ّم‬ ‫ع‬ ‫ّو‬ ‫إن‬ ‫حكيت‬ ‫ّو‬ ‫إن‬ ‫هوه‬ 3 ‫شي‬ ‫أحسن‬ beautiful ‫شي‬ ‫أحسن‬ ‫هي‬ i can talk to my husband and make sure he is fine and he also can make sure that we are fine thats the best thing beautiful the best thing farah farah lives in camp with her three children although a slow reunification process keeps her husband at a distance the intense feelings of love farah has for and shares with him facilitate affective forms of reorientation that keep him close farah chats with her husband on facebook messenger and voice and video calls him on whatsapp they speak every day every two or three hours 4 this is their way of practising copresence of feeling and being together at a distance in her study of the cultural politics of emotion sara ahmed contends that emotions are more than psychological states they are deeply related to social and cultural practices affects are relational shaped over time by contact with or orientations towards and away from objects and others and the impressions left behind while ahmeds use of emotion has been critiqued it is her understanding of emotions as relational and material that guides this exploration of affect in this article i use emotion affect and feeling interchangeably these terms serve more like keywords points of departure for conversation rather than definition although i acknowledge that affect emotion and feeling are contested terms in scholarship i am not particularly interested in defining or parsing out the differences between them nor do i see the value of isolating them as distinct facets of experience rather i am interested in what emotions do and how they help constitute particular forms of agency farah carries her phone on her body at all times whether at home or when attending activities in the camp when she speaks about her husband she touches her phone with her hand or holds it against her chest as a wearable device capable of archiving and sharing affective material the physical digital and emotional infrastructures of the smartphone make it uniquely embodied in her study of the mediation of waiting within iraqi refugee households in jordan mirjam a twigt uses the concept of affective affordances the capability of media use to impart affects to explore the ways mediated attachments enable people to stay optimistic and endure the present yet hopefully orient themselves toward particular futures affective affordances are exemplified by farah whose smartphone not only mediates her relationship with her husband but also hopefully orients her toward feelings of reassurance and the possibility of a good life with him in germany once their family is reunited in the meantime farah uses the affective affordances of her smartphone to mediate and maintain her family unit while some scholars have noted the negative implications of mediated copresence for example the potential of increased conflict or social surveillance among my participants smartphones were significantly oriented towards positive feeling and despite their panoptical potential were viewed as an essential tool for enduring camp life politicising space time and liminality building upon the previous discussion of emotions this section elaborates on the spatiotemporal positioning of refugees waiting to travel onwards arguing that the experience of waiting is suffused with emotions while timespace compression would have us believe that information and communications technologies are annihilating time and space i will argue that on an emotional level time and space are always affectively felt forced migrants are especially aware of the boundaries that keep them separated from loved ones boundaries which often exist due to forces beyond their control with this in mind it is necessary to consider the ways that social differences such as gender race class religion and immigration status are imbricated in migrants daily lived experiences of time and space refugee camps especially are not neutral sites of humanitarianism but rather politicised assemblages of different social institutional and diasporic relations and practices digital technologies do not collapse these tensions but rather exacerbate them for example in the context of smartphone ownership and the european border regime the racialised connected migrant does not fit the somatic norm of a smartphone owner and is perceived as a territorial threat this construction is not only racialised but also gendered embedded in the related binaries of agentvictim and as riskat risk in which the unaccompanied male muslim agent is constructed as risk while the vulnerable female victim or more often a massified womenandchildren is at risk such constructs of invulnerabilityvulnerability communicate that there are specific categories of people in whom vulnerability inheres and imply that there are invulnerable others who should be feared by fixing people in gendered categories that promote rather than prevent their distortion these binaries work to erase her agency and his vulnerability however exclusion is not only experienced in spatial terms as sarah sharma argues immigration status is itself based on a set of spatial exclusions and restrictions but they are temporally experienced for example while refugees await resettlement they may live without forms of temporal maintenance such as health care education or legal employment all of which allow refugees to advance or at the very least sustain their lives yet in migration studies displacement is often described in spatial terms when temporality is considered the concept of liminality is often applied where liminality represents a temporal passage betwixt and between flight and socalled durable solutions repatriation integration or resettlement however critical scholars have problematised such framings of liminality which according to georgina ramsay imply a linearity of experience and characterise the refugee as a particular category of experience rather than as a person with a history a present and an imagined future that are shaped through personalized experiences i would add that invoking the liminal implicitly negates the present for example adam ramadan proposes refugee status as an embodiment of liminality not a normal life to be lived but an enduring struggle for survival and return to a time and place of meaning while a refugees life is indeed a precarious life such a focus on liminality if left unscrutinised may preclude agency if the past and future are meaningful is the present then meaningless such a negation of the present cannot serve refugees whose experiences of waiting are happening now are ongoing and are affectively felt at the same time it is often the case that refugees themselves characterise their own experience as stuck waiting or in transit this begs the question how do we honour the ways refugees describe their own experiences in time and space while also problematising uncritical invocations of the liminal that serve to universalise refugee displacement as a linear experience rather than as personalised agentive and filled with struggle i do not claim to have an answer to this question rather i offer it as an invitation for further deliberation in the next section i will elaborate on my understanding of waiting and explain how refugees make do with protracted experiences of waiting making do with protracted experiences of waiting for refugees stranded in greece waiting is a deeply affective experience however rather than drawing on liminality i draw on lauren berlants notion of impasse as a stretch of time in which one moves around with a sense that the world is at once intensely present and enigmatic berlants description of impasse resonates with this articles epigraph where rania describes feeling here but not here for rania waiting is an affective spatiotemporal experience of location embodiment and orientation waiting is experienced here as well as not here waiting is not a passive process it requires emotive labor and involves struggle here struggle is less about dramatic resistance but rather the doing of little things the ordinary the mundane the everydaywhich does not have the sense of a passive submission but of an active engagement in order to explore this understanding of struggle i use the dialectic of strategy and tactics where strategy refers to the disciplinary actions imposed by those who exercise power and tactics refer to the agentive actions of those who are subjected to power in the context of migration strategy is enacted through militarised and mediatised border regimes as well as the institutionalisation of migrant detention centres and refugee camps tactics meanwhile are the everyday actions the doings of little things that allow refugees to persevere however as will become evident in the empirical sections strategy and tactics are not an eitheror the two are deeply related and tactics may fail backfire or end up constituting that against which they are directed this article is specifically interested in the ways migrants mobilise their phones in order to engage emotive tactics that allow them to make do with protracted experiences of displacement by providing a way for refugee women to live with the ambivalent contesting emotions produced through protracted experiences of waiting i argue that mediated practices of making do constitute particular forms of agency in the following methodological sections i will contextualise the material conditions of the refugee camp and position myself as a researcher as will become evident my methodology is deeply embedded in feminist practices exploring fieldwork contexts from february 2017 to may 2017 i undertook fieldwork at a semipermanent 5 open refugee camp in mainland greece though residents originally lived in tents on a small section of land the camp had recently been winterised between 650 and 800 residents now lived in 158 numbered isoboxes referred to by residents as caravans these isoboxes were assigned by the international organisation for migration who acted as official camp management as an open camp residents were free to come and go as they pleased though long absences could result in eviction however an open camp also meant that anyone could enter which posed protection risks as the camp was unpatrolled and no special permission or clearance was required in terms of camp organisation it was difficult to regulate practices and processes among actors when anyone or any organisation was allowed in in addition as journalists and even tourists could enter and take photos as they wished the open camp maintained the gaze facilitated a spectatorship of suffering and perpetuated disempowering narratives of refugees as vulnerable victimised others yet despite the drawbacks of an open camp many residents preferred this to the alternative asserting i can choose who i want to talk to had i conducted my fieldwork in a closed camp my fieldwork would have been different at the camp i volunteered in an ngos 7 womens space a private fencedin area designated for women and girls aged 12 and above as a volunteer i worked alongside the ws coordinator and the genderbased violence protection officer in order to perform outreach to all women at the camp and facilitate mental health and psychosocial support activities while i am critical of the paternalism invoked by protection programmes and of the organisation for which i volunteered i also recognise the importance of community spaces for women especially in environments that offer little privacy in addition to the ws the ngo ran a childfriendly space which acted as the camps primary day care centre and a youth engagement space a number of other actors were active in the camp for example the red cross which ran a medical clinic ws and mens space doctors without borders médecins du monde and various ngos that provided art and language classes ran a community kitchen supported a communityrun library andor were responsible for distribution of catered food as well as nonfood items in addition several residents in camp had set up their own shops for example a barbershop and a falafel stand the latter a popular lunch spot among ngo staff and volunteers prior to my arrival the united nations refugee agency had maintained a visible presence at the camp however following the death of an infant for which the community blamed unhcr the agency had minimised its visibility in terms of transportation a bus service coordinated by iomunhcr provided transit for children attending local schools as well as residents with asylum interviews or doctors appointments with the remaining seats available on a firstcome firstserved basis without these buses the mobility of residents would be extremely limited as no public buses stopped nearby and taxis were not only expensive but some refused to travel to the camps remote location although a detailed intersectional analysis goes beyond the scope of this article i will briefly highlight several ways that camp composition and organisational structure created or exacerbated inequalities during my fieldwork the camp was racially religiously and ethnically diverse however ethnicity was a particularly significant identity marker syrian residents by far the largest population in camp often selfidentified as syrian arab or syrian kurd this difference was important to residents and created social as well as material divisions six somali women who did not know one another prior to arriving in greece were placed together in an isobox an assignment based off of their racialisation alone despite the fact that they were the only black women in camp their isobox had been arbitrarily placed on the camps perimeter delal suffered a spinal injury during her familys boat crossing to greece and required a wheelchair however the camp which was filled in with gravel was not wheelchair accessible it was not until she was seriously injured which for privacy reasons i will not elaborate on that she and her family were moved to an apartment in athens the camp was located along a lowflying military training route and several times a day the sound of airplane engines thundered overhead this sound which had become a part of the camps ambient noise enacted structural violence on residents as it reminded many of the sounds of conflict from which they fled while there was wifi at the camp the signal was weak and did not work inside isoboxes which forced residents to go outside for internet access for this reason many residents opted to purchase monthly data plans using the small monthly allowances provided by the red cross or with their own funds however these data plans were not sold in camp residents had to travel to the nearest greek town or to athens both of which would cost considerable time and money in each of these examples inclusion exclusion and oppression are heterogeneous and interlocking why did you come here reflections on positionality as a white woman with canadianirish citizenship the mobility provided by my privileged position stood in stark contrast to the precarity of the residents i interacted with on a daily basis during my fieldwork a reflexive research process has kept me conscious that however benevolently motivated my research may be the knowledge produced through research is always partial and has the potential to enact forms of epistemic and symbolic violence while recruiting participants one resident asked me pointblank why did you come here a question which struck me although i had written a research proposal that emphasised ethical practice it was not until this interaction that i understood the importance of situated positioning which is the aim and benefit of feminist research practice power relations and contested identities are always active unstable and lived and so they must be continuously recognised and negotiated in the field which is inevitably messy importantly humbling in her discussion of vulnerable writing tiffany page considers the potential for violence when representing and attempting to produce knowledge from the lives of others pages notion of vulnerable writing encourages me to disclose the interaction above a residents questioning of my positioning rather than omit it from this output i believe that within an affirmative and ethical research design methodological challenges offer opportunities for reflection and should be recognised as generative parts of the research process rather than treated as failures scholarship that is truly invested in minimising harm must be attentive to the microand macropolitics that are inevitably enacted through our work these tensions play out materially in our fieldwork but also discursively in our attempts to make sense of the experiences of others for this reason a significant portion of this methodological section has been dedicated to engaging with questions of power positionality knowledge and context while i understand that acknowledging these issues does not guarantee the production of critical responsible research as farhana sultana notes the alternative of not heeding such issues is even more problematic ethical implications have material consequences and no research is so pathbreaking as to justify exploitation with this in mind i am cautious of how i represent the very real women whose time and care made this research possible in this article i have aimed to write in a way that is receptive vulnerable and embodied in order to think critically and reflexively about how to produce knowledge that is not only attentive to nuance and complexity but also affirms and honours the lives of the women i was privileged to know intimately feminist research design and methods ‫بتشوفيها‬ ‫انتي‬ ‫بس‬ ‫هي‬ ‫ألكسندرا،‬ ‫ذكرى‬ ‫عندك‬ ‫تتم‬ ‫مشان‬ ‫هي‬ this is to remain as a souvenir alexandra only you can look at it given the subject of my research and the fact that my participants represent only a small sample of a highly heterogeneous community it would be impossible to quantify their experiences thus in order to foreground lived experience emotionality and embodiment i used qualitative research methods this article focuses on the situated experiences of 15 particular women ethnographic fieldwork consisted of daily participantobservation in personal caravans the ws the camps public spaces as well as indepth interviews and photo elicitation hanging out with residents and volunteering with one of the humanitarian actors in the camp afforded me a deeper understanding of residents media use in relation to lived experience emotionality and embodiment indepth interviews followed a semistructured interview guide written in english and translated into arabic which explained the purpose aims and goals of my research and included various questions and prompts relating to smartphone use and emotionality as i was not fluent in the first languages of camp residents i mainly recruited participants whom i knew spoke english well thus interviews were conducted mostly in english with some exceptions for example in my interview with farah i shared my arabic interview guide with her and had our conversation translated into english with wardah i used texttospeech software as she was semiliterate interviews were conducted onetoone or in small groups either in participants caravans or in the ws when needed friends or family acted as informal translators all participants consented to interviews and to being audiorecorded in the case of minors parents or guardians were present to provide consent interviews were entirely voluntary and participants were free to withdraw participation at any time in all cases anonymity was protected through the use of pseudonyms interviews were transcribed verbatim in english or in arabic and coded inductively using qualitative data analysis software in order to safeguard my participants data all recordings and transcripts were saved in a passwordprotected folder in my laptop interviews included a photo elicitation exercise structured around w5h questions during which participants were invited to share their social media profiles and digital content including images videos and posts while the use of photographs was initially only one aspect of my methodology images became central to my data collection and the lived practice of reflexive and vulnerable research photo elicitation provided an opening for participants to guide the interview and speak more candidly about emotions i too shared personal photographs and the stories connected to them by doing so i put myself in a position of vulnerability where my images were subjected to participants scrutiny interpretation and possibly judgement however this vulnerability also created a sense of shared intimacy between me and my participants which in turn fostered more trusting relations it is important to note that although private personal photographs were shared with me i was not always given permission to photograph or reproduce these images for example when farah shared a selfie of her and her husband in athens she told me this is to remain as a souvenir alexandra only you can look at it even in the case of images given to me with consent in order to safeguard my participants data and out of respect for the personal information shared during interviews i have been cautious about which i reproduce in this article for this reason i consider the images that appear here as not only representations of participants photographs but also documentations of intimate research encounters in the following empirical sections i will explore three examples of making do nonmainstream news consumption as a tactic of selfcare mediated family practices as a tactic of hope and nature photography as a tactic of creativity making do nonmainstream news consumption as a tactic of selfcare for refugees stranded in greece waiting is a deeply affective and embodied experience during my interview with rania i learned that her parents remain in syria when i asked her whether she followed the news in order to stay updated on events back home her answer surprised me uhh not really if i always follow the news uh maybe i will be crazy because uh everyday many people kill die and uh bomb bomb everywhere so always i will be nervous and uh thinking so i have to be more strong because you know im woman here alone and with child if i uh be so nervous its not good for my baby and uh maybe i can uh i cant uh do my uh what i have to do in right way yet i had not considered that the news could be such a source of distress as most research on migrant news consumption characterises migrants as newshungry i had even expected the people i encountered at camp to be politically active an assumption that i had unknowingly carried with me into the field when for the most part they were just trying to survive however far from an act of passivity ranias practice of not following the news demonstrated agency whereas news from the mass media made rania feel crazy or nervous news that she got from the people meaning directly from her personal network helped rania to be more strong for her child a sentiment that was also expressed by other participants with young children scholars have argued that in all countries especially in conflictaffected countries politics are fought out in the news as news media is never neutral personal relationships play an important role in newsgathering practices whether it be because friends and family are considered more trustworthy or because it is more pragmatic for example for wardah who is semiliterate reading news online is not a realistic option websites i dont understand instead she relies on getting her news through wordofmouth either over the phone or from people in camp nevertheless there are drawbacks to such practices of filtering for example the news shared by personal networks is partial and selective there is always a risk that important information may not be shared although as noted earlier there are also biases among mainstream news networks despite these drawbacks participants considered their loved ones representations of the news to be the most reliable those one best suited to their needs finally just as the personal is political the emotional is material feelings whether positive or negative impact individual abilities to perform everyday actions which rania implies when she says if i be so nervous i cant do what i have to do in right way indeed emotions matter they shape the surfaces of bodies as well as worlds not only must rania and the other women in this study live with the pain of separation they must also negotiate the everyday realities of having friends family and a home in persistent danger all the while negotiating their own protracted experiences of displacement and uncertainties about what will happen to them andor their loved ones although rania is concerned about her familys safety in syria she recognises that selfcare caring for ones health and wellbeing is necessary in order for her to persist and support her son rather than feel utterly defeated by her circumstances rania chooses to make do on her terms in the context of a dehumanising border regime ranias nonmainstream news consumption as a tactic of selfcare demonstrates agency in the next section i will further explore the importance of emotions in negotiating protracted experiences of displacement and family separation making do mediated family practices as a tactic of hope for refugees stranded in greece waiting is a deeply affective and mediated experience lulu is a syrian kurd from hasakah in northeastern syria she has been in greece for 8 months with her son sisterinlaw and nephew in syria she studied arabic in university but i didnt complete because dom dom imitating the sounds of bombs when the war intensified lulu fled syria with her husband lulu remained in greece while her husband travelled onwards to germany since then lulu has given birth to their son who her husband has not yet met in person their entire relationship has been mediated through lulus and her husbands respective smartphones every day she sends him photos and videos of their son through whatsapp each phone call picture and video only increases their desire to be together yet for refugee families like lulu and her husband poor internet connections audio and image lags dropped calls and frozen screens are ubiquitous and the everyday digital practice of doing family can best be characterised as a life of waiting despite the affective affordances of their smartphones digital copresence remains a substitute for physical copresence and living apart is affectively experienced whether it involves waiting for the outcome of their reunification application waiting for a scheduled voice call or waiting for whatsapps single grey checkmark to double into two grey checkmarks and finally into two blue checkmarks there is always an anxiety stirred by waiting for news or information and there are always wait times within and further compounded by these moments of waiting these examples of technologically incorporated waiting underscore the ways in which waiting is mediated multiple personal and situated to compensate for these feelings lulu and her husband orient themselves towards the future during our interview lulu describes how she comes to know her husbands city through the selfies he takes she showed me pictures of her husband in front of his language school the university and various city landmarks not only are the images curated by her husband but the images themselves are imbued with good feeling since lulu is happy to receive photos from him however lulus future expectations extend beyond these images yesterday i said my husband if i come to germany i will complete my study and uh after that i will baby another baby haha lulus aspirations for the future are embedded in a fantasy of the good life characterised by family security and social upward mobility scholars argue that such fantasies of the good life offer refugees a source of inspiration and hope and make precarious conditions more bearable indeed for lulu hope is a generative action working towards an idea of the good life offers a form of creative mobility that hopefully orients her towards the future however as berlant argues the fantasy of the good life can be a source of cruel optimism that is when something you desire is actually an obstacle to your flourishing the desire to be resettled in europe the outcome desired by all my participants is an example of cruel optimism because resettlement will not necessarily resolve the problem of their displacement the immigration regime extends beyond refugee camps from legal and cultural notions of citizenship to child welfare systems unfortunately many refugees only discover after resettlement that displacement is neither liminal nor linear take the case of farahs resettlement as an example in october 2017 i visited farah and her family in their new home in germany farah waited over a year to be reunited with her husband in camp her smartphones affective affordances mediated and maintained her family unit and kept her hopeful for the future as soon as possible she had wanted to resume their life together a new life a better life a good life yet her life in germany has not been better or easier than her life was in greece and the problem of her displacement has certainly not been resolved while she her husband and her children no longer endure the pain of separation in the small town in east germany where they have been resettled their neighbours are unwelcoming and there are limited resources and opportunities available to them the fact that farah has been resettled and yet still lives precariously highlights the insidiousness of the immigration regime and emphasises why it is necessary to move beyond framing the displacement of refugees as a liminal condition while there is nothing inherently wrong with fantasy in lulus case fantasy provides a form of creative mobility that allows her to endure her present conditions it is necessary to identify its shortcomings as a fantasy the good life that is aspired to by some may not be achieved sometimes the fantasy of the good life is only that a fantasy this section has shown how mediated family practices facilitated through the smartphones affective affordances allow refugees like lulu and her husband to make do while living apart and remain hopeful about the future while also drawing into question whether or not that future will transpire as desired in the next empirical section i will further explore the potential of creative mobilities making do nature photography as a tactic of creativity building upon the previous two cases of making do this final empirical section uses nature photography and the smartphones affective affordances to explore how living in waiting is a deeply affective embodied and mediated experience during the photo elicitation exercise i invited participants to share a favourite photo from their smartphones image archive among the most popular were photographs of nature these images were selected for various reasons such as for their aesthetic qualities or for the memories attached to them for lulu a photo of the sunset is her favourite because i see its very beautiful lulu likes the way the light changes as the sun goes down noting this colour i like i love this however the photo is also special to her for another reason when she shared it with her husband he made it his whatsapp profile picture lulu laughs when she tells me this as though to downplay it but she also lights up and i can see that this small action on his part is not insignificant to her in this way the smartphones affective affordances for taking saving retrieving and sharing photos contribute to an archive of feelings within the phone itself lulus photo of the sunset is a favourite not only because of its aesthetic qualities but also because the photo was shared with and affirmed by her husband for rozhin a 19yearold woman from kurdistan a photo of the sky is her favourite rozhin captured this image shortly after she and her family arrived on the greek islands rozhin in chios we are waiting for the bus and i look the sky and take the picture alexandra how do you feel when you look at it rozhin im mostly just like uh fly just like flying fly in the sky like free i dont know make me happy the sky make me happy this photo is certainly important to rozhin because of the time and space in which it was captured the image celebrates her and her familys safe passage across the aegean however it is more than this as a subject the sky is a borderless space of fantasy freedom and flight in our conversations rozhin and her sister aawaz often expressed dismay over their idleness in camp in kurdistan they had busy social lives but in camp the absence of interesting activities close friends and a clear future forward made them feel stuck ann cvetkovich argues that when confronted with feelings of stuckedness creativity can encompass different ways of being able to move to solve problems have ideas be joyful about the present make things for rozhin nature photography offers such forms of agency since leaving the refugee camp i have maintained contact with several participants including rozhin many of the youth i interviewed are active on social media and have since added me on platforms such as facebook instagram and snapchat i have noticed that these young women frequently share photos and videos of the natural environment on their social media accounts participants share videos where they walk through quiet areas of camp or film landscapes through the closed windows of moving vehicles it is common for traditional arabic or kurdish music to accompany these nature videos which are typically shared on snapchat or in instagram stories disappearing after 24 hours in her study of the mediation of hope twigt observes being considered out of place further pushes the iraqi refugees to orient themselves beyond the virtual to other physical places where futures are deemed possible the virtual is used to conceive these other physical places despite their transience the videos shared by my participants feel like creative engagements with such spaces especially when paired with musical accompaniment the videos feel like more than encapsulations of a fleeting present they feel as though they are part of something material and enduring by mobilising the affective affordances of their smartphones in order to capture archive and share images participants affectively orient themselves elsewhere while displacement involves an uprooting of spatiotemporal positioning this final empirical section has used nature photography to show how creativity offers a way to make do with this unsettling conclusion in this article i have shown how waiting is a deeply affective and embodied experience mediated by smartphones and tempered both spatially and temporally using a reflexive and vulnerable methodology this article has drawn upon the particular situated and contested experiences of 15 women waiting in a refugee camp in greece in order to make three interventions first this article has sought to affirm refugee womens voices and experiences as valuable sites of knowledge production second this article has questioned prevalent discourses that represent displacement as a liminal condition it has done so by politicising refugee temporalities particularly the negation of the present and by problematising resettlement as a solution to displacement third this article has conceptualised the way that strategy and tactics figure into the everyday lives of refugees it has done so by arguing that mediated practices of making do understood in this article as emotive everyday spatiotemporal tactics constitute particular forms of agency which provide ways for refugee women to live with the ambivalent contesting emotions produced through protracted experiences of waiting this article has explored three mobilities or tactics that mobilise the smartphones affective affordances and may be engaged while waiting nonmainstream news consumption as a tactic of selfcare mediated family practices as a tactic of hope and nature photography as a tactic of creativity it is important to note that while these tactics allow women like rania lulu and rozhin to make do with their experience of displacement there are limitations to such tactical interventions and experiences of displacement are always personal and differentiated for this reason these tactics were never presented as solutions to displacement but rather as specific practices which allow particular women to endure and move within particular conditions of precarity the emotive tactics of making do explored in this article serve as forms of agency within a dehumanising strategy of migration control and as such offer an important intervention in the regime of waiting while the mediated mobilities offered by selfcare hope and creativity may not be as mappable as migration journeys i have argued that they are valid and meaningful forms of movement that deserve greater attention engagement and study within migration scholarship notes 1 the majority of residents at the camp would eventually be resettled either through reunification or relocation procedures although the wait times were long and varied 2 while i use the contested term refugee it is necessary to emphasise that refugees are not a monolithic group rather refugees are individuals with personalised experiences and aspirations in addition i use the label refugee women not as a category but in order to foreground gender in my argumentation 3 all quotations by participants are transcribed verbatim in this case arabic is spoken in a syrian dialect so it is written this way rather than in ‫الفصحى‬ modern standard arabic 4 original quote ‫معو‬ ‫بحكي‬ ‫ساعات‬ ٣ ‫كل‬ ‫ساعتين‬ ‫كل‬ ‫يوم،‬ ‫كل‬ ‫يوم،‬ ‫كل‬ 5 a semipermanent refugee camp is expected to exist for 3 to 5 years 6 in greece closed camps are patrolled typically by the military and movement in and out is regulated which leads to an increased feeling of detention within an already carceral environment while residents of the camp where i was based were mostly syrian residents of the nearest closed camp were almost entirely afghan and thus ineligible for relocation under the 2015 emergency eu relocation agreement 7 in order to safeguard the identities of my participants i do not disclose the name of the ngo for which i volunteered biographical note alexandra greene is a feminist researcher with a background in gender media and migration she is a phd candidate at the department of sociology at vrije universiteit amsterdam

doi link to publisher 1011771367549419869346 document version publishers pdf also known as version of record document license article 25fa dutch copyright act greene a 2020 mobiles and making do exploring the affective digital practices of refugee women waiting in greece

introduction owing to spatial interactions made possible by modern transportation systems the deadly covid19 diseasewhich was first reported as a cluster of viral pneumonia in wuhan the provincial capital of hubei in china on 31 december 2019quickly spread to worldwide 12 studies show that by 31 january 2022 a little above 29 million sarscov2 daily infections have been reported globally 3 recent studies even caution against the socalled postcovid19 conditions long covid or longhaul covid including pulmonary cardiovascular neurological and physical disorders which are emerging worldwide 45 for instance ref 5 estimates that nearly 1 in 13 us adults either with or without a previous covid19 diagnosis currently have postcovid conditions the possible causes of this trend are difficult to pinpoint however it cannot be overemphasised that as the pandemic continues there is the need for extra vigilance further scientific knowledge and strategic public health campaigns to engender strict compliance to the covid19 protocols as were rolled out during the first wave of infections in 2020 ghanas covid19 cases were first reported in accra the national capital on 12 march 2020 6 by the end of march 2020 ghana had confirmed 152 new locally transmitted cases with a death toll of five victims and a recorded 22 recoveries 7 consequently several emergency response measures were introduced to minimise the communal spread of the virus table 1 summarises mitigation protocols explicitly mandated for public transport operators and users as well as the issuing institutions of the state for instance the parliament of ghana promulgated act 1012 to provide the legal basis for the presidency to impose a lockdown order the lockdown took effect in accra and its contiguously builtup area known as the greater accra metropolitan area and the greater kumasi area in the ashanti region between 29 march 2020 and 20 april 2020 offenders of act 1012 were liable for a summary conviction a fine of between ghs 12000 and ghs 60000 and a jail term of between 4 and 10 years in addition the government of ghana embarked on a massive public health campaign through traditional and social media outlets all over the country 8 the safety campaigns provided ample information about the virus its mode of spread and mitigation measures additionally various state and nonstate actors donated sanitary items to help public transport operators in the fight against the pandemic the ministry of transport for instance donated 200 veronica buckets 200 plastic bowls 800 pieces of hand sanitisers 400 pieces of detol 400 pieces of liquid soap 400 pieces of tissue and 300 pen drives containing recorded messages on good hygiene two major ridehailing companies uber and bolt were each given 40 pieces of hand sanitisers 20 pieces of detol and 20 pen drives 9 mitigation protocols issuing authority enactment of imposition of restrictions act 2020 the parliament lockdown of accra and kumasi the presidency easing of lockdown and announcement of enhanced mitigation measures against covid 19 the presidency physicalsocial distancing in vehicles eg taxisridehailing services to reduce the total number of passengers from four to three per trip ministry of transport transport terminals to ensure adequate running water basins and sanitisers for the use of passengers before boarding ministry of transport commercial drivers to record contact details of commuters to ensure contact tracing when necessary ministry of transport commercial drivers to thoroughly wash and disinfect vehicles after each trip ministry of transport enforcement of mandatory wearing of face masks by commuters greater accra regional coordinating council educationsensitisation on face maskwearing socialphysical distancing by the various mmdas in their jurisdiction greater accra regional coordinating council commercial drivers to ensure all passengers wear face masks before being allowed to board their vehicles greater accra regional coordinating council notices of no face mask no entry to be visibly displayed at vantage points including offices lorry stations and shops among others greater accra regional coordinating council earlier exploratory observational studies assessed compliance with covid19 mitigation measures in accra results show that hand washing at public transport stations was woefully infrequent and in most instances only a few passengers wore face masks 10 similarly fewer public transport users wore face masks in kumasi meanwhile physical distancing measures were strictly enforced 11 in these two major cities the technologyenabled ridehailing services operated by transportation network companies such as uber bolt and yango among others are popular public modes of transport 12 public transport has been identified as a potential source of covid19 infection 10 proximate seating patterns in public transport have become fertile grounds for transmitting the infectious virus especially as drivers and passengers come into direct or close contact with other people on board who may be asymptomatic covid19 carriers a knowledge attitude and practices survey is defined as a quantitative method that provides access to quantitative and qualitative information 13 these surveys generally measure peoples perceptions and opinions which may serve as triggers or constraints on behavioural change this paper focuses on the kaps of ridehailing operators in ghana given the urgency to develop effective public health and infection prevention measures to break the chains of transmission in the transport sector this is becausedespite the evolving knowledge of the science of transmission of the virus by which the government engages the public through several agencies and media housesthere is a huge lacuna in knowledge among the population with reflections on safety practices belief systems and conspiracy theories abound both globally and in ghana outside the established who science which may produce a counter trajectory of behaviour among the population earlier kap studies 14 15 16 17 18 19 20 have provided better scientific insights on developing preventive strategies and health promotion programs among the general population and among frontline health caregivers college students villagers dental academics and public hospital visitors however ridehailing operators appear not to have received any particular focus so far in the scientific debates scientific evidence of drivers appreciation of the gravity of the pandemic and their compliance with the highly publicised covid19 protocols in addition to their insistence on clients compliance is an essential milestone for achieving the health and transport authorities targeted interventions seeking to curtail the communal spread of the virus thus the threefold specific objectives of this paper are to assess covid19 knowledge levels among drivers their attitudes towards the pandemic and their recent practices deriving from the need to stay safe conceptual framing the health belief model this study adopts aspects of the health belief model as its analytical framework the hbm conceptualises the healthrelated behaviours of individuals on the premise that humans generally want to avoid illnesses or desire to become well soon after they become ill thus individuals will pursue specific health action that prevents or cures an infection in other words an individuals belief in a personal threat of an illness or disease and the efficacy of a recommended health behaviour or action will predict the likelihood that that individual will adopt a proposed behaviour an individuals health behaviour is also a function of their health literacy status defined as the degree to which individuals have the capacity to obtain process and understand basic health information and services needed to make appropriate health decisions 21 besides personal health literacy the role of organisations in promoting health literacy and services particularly during disease outbreaks for example covid19 is critical in achieving equitable health 22 within the context of the hbm health behaviours and responses to proposed interventions are because of the interplay among factors such as a persons perceived threat to sickness or disease the belief of consequence and the potential positive benefits of action the rest are perceived barriers to action exposure to factors that prompt action and confidence in the ability to succeed additionally the sociodemographic profile of an individual and psychological factors including their personality and pressure from their significant others are known to influence healthrelated behaviour this paper adopted the hbm as an explanatory framework due to its extensive application in recent studies that explain preventative behaviours they include positive behaviours against malaria among filipino migrant workers and taiwanese returnee migrants 2324 as well as against dengue fever among malaysian high school students 25 and covid19 vaccination outcomes among the general pakistani population 26 these studies unanimously found that participants improvement of knowledge perceived severity benefits and barriers directly impacted positive preventative behaviour and good health outcomes to illustrate for instance a study found that saudis who perceived the severity of respiratory infections to be high responded positively to health campaigns to regularly sanitise their hands and mask up when sneezing or coughing 27 a recent study has also adopted the hbm to gauge and explain the compliance of informal paratransit operators to the masking up protocols in ghana like the earlier studies older drivers who perceived their vulnerability to covid19 to be high consistently complied with face mask use 8 in light of the studies mentioned above this present paper proceeds with the hypothesis that there is a statistically significant difference in covid19 safety practices among the demographic characteristics of participants in the study materials and methods study sites and population the overarching objective of this paper is to measure the knowledge attitudes and practices of ridehailing operators in accra ghanas national capital and home to an estimated population of over 5 million as well as in kumasi ghanas second most urbanised area with an estimated population size of over 3 million 28 to achieve this objective a crosssectional design was used to generate quantitative data largely through a selfadministered questionnaire survey deployed on the kobotoolbox platform the various study sites are illustrated in figures 1 and2 research design this study adopted a complementary mixedmethods approach involving quantitative and qualitative data collection techniques quantitative data regarding the quantitative data a multistage systematic sampling technique was adopted in selecting study sites and respondents at the first stage of the sampling all locations designated for higher education formal commercial centres such as shopping malls and supermarkets telecommunication offices governmentpublic offices and airports where ridehailing operators are most likely to concentrate their services were specifically extracted from google maps and imported into an excel spreadsheet the application of google maps proved very useful in the sense that this mapping and consumerbased web application allows users of smartphonesone of the basic tools for ordering ridehailing servicesto review and rate locations and businesses they have visited high user ratings may suggest that such locations are very popular with netizens thus at stage two of the sampling procedure sixteen highly rated specific sites where various formal sector jobsoffices and educational institutions are located were selected these included tertiary institutions shopping malls supermarkets telecommunication offices governmentpublic offices and airports where formal sector employees and studentswho are the primary users of ridehailing servicesusually visit stage three included the purposive sampling of popular markets and informal commercial centres such as research design this study adopted a complementary mixedmethods approach involving quantitative and qualitative data collection techniques quantitative data regarding the quantitative data a multistage systematic sampling technique was adopted in selecting study sites and respondents at the first stage of the sampling all locations designated for higher education formal commercial centres such as shopping malls and supermarkets telecommunication offices governmentpublic offices and airports where ridehailing operators are most likely to concentrate their services were specifically extracted from google maps and imported into an excel spreadsheet the application of google maps proved very useful in the sense that this mapping and consumerbased web application allows users of smartphonesone of the basic tools for ordering ridehailing servicesto review and rate locations and businesses they have visited high user ratings may suggest that such locations are very popular with netizens thus at stage two of the sampling procedure sixteen highly rated specific sites where various formal sector jobsoffices and educational institutions are located were selected these included tertiary institutions shopping malls supermarkets telecommunication offices governmentpublic offices and airports where formal sector employees and studentswho are the primary users of ridehailing servicesusually visit stage three included the purposive sampling of popular markets and informal commercial centres such as okaishie druglane and the makola market as well as the asafo and kejetia markets as study sites from our experience these informal geographic spaces are known to attract a large number of tripmakers to the central business districts of these two major cities to engage in informal commercial activities thus it was reasonable to expect to locate ride hailing operators in these locations as well however these informal spaces seldom received mentions and reviews on google maps therefore we assumed that their diminished presence on google maps might not imply less patronage instead most trip makers in the informal sector do not necessarily use these hightech application tools such as google maps the fourth and final stage of the sampling involved the random selection of study participants at the study sites the surveys were conducted simultaneously in both cities from 25 january to 4 march 2021 research assistants installed the ridehailing apps uber bolt and yango and randomly booked rides once the vehicle arrived the assistants politely introduced the survey to the drivers and consenting drivers were paid for the booking the trip was then cancelled on the apps for the interviews to commence this was how drivers were invited to participate in the study in most instances this approach was adopted because during a pilot of the survey most participants abruptly abandoned the survey as soon as riders ordered their service at other times the assistants took notice of the major rest stops where most ridehailing drivers took their breaks and met to chitchat with each other they were invited to participate in the survey and willing participants volunteered information without demanding any form of compensation eligible participants were supposed to respond yes to the question as an uber bolt or yango partner driver have you driven at least 4 rides to be included in the survey in all one thousand and fourteen respondents took part in the survey in the design of the survey instrument we took inspiration from kap measures developed in two previous studies which were conducted in malaysia and china 1529 the questionnaire was sectioned into four parts including the sociodemographic details of participants such as gender age education marital status ridehailing type and city of residence in addition questions bordering on participants knowledge about the covid19 pandemic as well as general attitudes and practices occasioned by covid19 were asked in measuring participants knowledge about the disease 13 items were adapted from the previous foreign studies indicated and were complemented with additional 5 specific items related to ghanas enhanced covid19 mitigation measures for public transport the knowledge items measured included covid19 clinical symptoms origin and mode of transmission as well as prevention and mitigation of covid19 for each item participants were expected to provide answers from the options true false or no idea one mark was given to each correctly responded answer while all wrong and unsure responses were assigned 0 points the maximum total score a participant can obtain ranged from 018 with a higher score indicating that one had ample knowledge about the covid19 pandemic on attitudes respondents were queried on whether they were worried about rising covid19 cases with answer options ranging from yes absolutely and yes but not as it was in march 2020 to no in addition respondents were asked do you perceive yourself to be vulnerable to covid19 and do you have confidence in the governments mitigation measures against covid19 respondents were provided yes or no responses to choose from regarding practices participants were asked to indicate whether they had visited crowded public places in the most recent past travelled in a public means of transport properly washed and sanitised their hands and used a face mask when leaving home the answer options were either yes or no the questions were presented to the participants in either english the colloquial street language pidgin or asante twi depending on the participants preferences the raw quantitative data were exported from the kobotoolbox platform into an excel spreadsheet and cleaned to improve data quality data were coded and analysed using the statistical package for social sciences 25 software preliminary treatment of the data regarding consistency and reliability resulted in a score of 072 on the cronbachs alpha reliability coefficiency scale implying that the data are robust consistent and reliable 1530 descriptive statistical analyses were later performed including frequencies and percentages the influence of selected socioeconomic and demographic independent variables on the dependent variables was regressed using the analysis of variance statistical tool additionally statistically significant differences among the constructs were assessed using pearsons chisquare test qualitative interviews short qualitative interviews were also conducted to allow respondents to present their lived experiences in their own words we adopted the qualitative method to explain and reinforce aspects of the quantitative findings and to explore deeper meanings of stated behaviour 31 survey participants were required to answer either yes or no to the question personally do you think you are vulnerable to contracting the covid19 virus as you regularly get in touch with strangers who board your car all who responded in the affirmative were further required to explain why you think youre vulnerable to covid19 infection this allowed participants to share their covid19 experiences in their own words several reasons were recorded verbatim and typed as text on the field in all 4218 words were extracted from the typed voices of the survey participants in response to the question in winnowing the data before analysis as pointed out by 3233 we used the find and replace command in microsoft excel to reclassify all synonymous words into more familiar words for instance words such as people other people other persons and strangers that appeared in the data were all replaced with the word passengers additionally words such as cash money and fare were replaced with the word cash the qualitative data were then imported into microsoft word and analysed for frequently occurring words using a pro word cloud generator we set the maximum words to 50 and further instructed the software to remove all common words in all 395 frequently occurring words were selected for instance the word passengers was used 315 times cash appeared 107 different was used 96 times by participants the output was then visualised as word cloud and presented as a figure the size of each word demonstrates how important it was to survey participants in explaining why they felt vulnerable to covid19 infection studies have shown that word clouds provide novel and readerfriendly approaches for analysing and presenting qualitative data 3435 further we allowed respondents to share their attitudes and general thoughts on the pandemic qualitatively the researchers saved the interviews using voice recorders on their smartphones the interviews lasted an average of ten minutes per participant voice recordings of selected survey participants were played back and transcribed verbatim by the first author the researchers translated directly into english for participants who spoke in the local dialects the first author thoroughly read highlighted and annotated relevant sections of the transcripts next the second author independently combed through highlighted and categorised all statements sentences or quotes from the raw qualitative data both authors then debated and developed clusters or categories relative to the hbm constructs to shed light on how participants perceived their vulnerability to and coping mechanisms to prevent covid19 infection this inductive coding was performed thoroughly until all categories in the data had been exhausted the coding categories include perceived susceptibility perceived severity perceived benefits and perceived barriers the researchers treated each statement as having equal worth we then adopted the textual description approach and presented participants covid19related lived experiences as direct quotes in the study to ensure the datas credibility and following previous studies we employed the memberchecking strategy by having some participants check the transcribed data for accuracy and clarification of information as has been conducted elsewhere 3637 we made contacts through phone calls to some of the participants to substantiate some of the direct quotes we had translated from the interviews to maintain the participants meaning and ensure trustworthiness authenticity and credibility as cautioned by 32 results demographic characteristics of participants the data are skewed disproportionately towards males who constitute 997 of the total 1014 participants in the survey few women operate ridehailing or even drive public transport in ghana hence resulting in their small share in the dataset the average age of participants was 32 years the participants had received at least 15 years of formal education and the majority had a senior secondary school certificate most drivers indicated that they mainly operate for the bolt ridehailing company regarding driving experiences as ridehailing operators the average period was 27 months table 2 summarises the rest of the background information on survey participants assessment of knowledge of the 18 items that were used to measure the participants knowledge about covid19 the average score recorded was 151 the correct aggregate score on the knowledge measures was 84 about 789 of participants scored 15 and above indicating an acceptably high level of knowledge of covid19 regarding knowledge of the clinical manifestations of the disease most participants knew that covid19 patients usually have symptoms such as fever runny nose dry cough sore throat and headaches on the origins and transmission items many respondents incorrectly thought that the virus could be transmitted through the consumption or handling of game despite this 969 and 868 respectively of participants correctly said that the covid19 virus spread through respiratory droplets and contact routes as well as airborne transmissions on how we can best control and mitigate transmissions most participants correctly said there was the need to practice frequent hand hygiene before touching eyes nose and mouth as well as exercising respiratory etiquettes of covering the nose and mouth when coughing or sneezing regarding the specific enhanced mitigation measures announced by the government of ghana for public transport operators the order on face mask use and the practising of physical distancing in vehicles were the most widely known measures that most participants scored correctly on the downside as many as 604 of participants scored incorrectly on the governments directive for drivers to write down the contact details of all passengers for possible contact tracing should the need arise see table 3 for a summary of the other findings assessment of knowledge as many as 96 of the participants indicated that they were anxious about the covid19 pandemic when asked whether they were worried or not about rising cases during ghanas second wave of infections in early 2021 as explained in the qualitative interviews as follows indeed we were extremely worried at the beginning of this year 2021 when we heard that new active cases were emerging some of us thought that the worse was over in 2020 but then we woke up only to realise that the disease had come again resurfaced i think the christmas and elections period 2020 general elections in ghana took away our attention from the fear we had from the beginning of last year so it is right now that the excitement is over that we are waking up to the frightening realities as shown in figure 3 a majority of participants who expressed fear about the rising covid19 cases however felt that their level of anxiety was higher during the first wave of infections in ghana sometime in march 2020 compared to the second wave most ridehailing drivers felt they were vulnerable to quickly catching the covid19 virus this notwithstanding most of the respondents believed in the governments covid19 management and were optimistic that the nation would ultimately overcome the pandemic the qualitative data reveal what seems to the source of the heightened anxiety among survey participants the drivers asserted that their work exposes them to passengers from different backgrounds whose covid19 and vaccination status may not be known to them additionally the exchange of physical cash at the end of trips instead of digital payment options predisposes the drivers to the threat of covid19 as seen in the following comments i strongly agree that we drivers are very much at a higher risk of catching the virus no matter how cautious you may be you are always picking up passengers who may be carriers of the disease some carriers may themselves be asymptomatic and before youre aware youre already sick and all that presently i havent taken the shot and i also do not have any means to confirm the covid19 health status of the passengers whom i serve so yes i think commercial drivers are as exposed as the frontline health care workers or even worse i say we drivers are exposed to the disease because see we take money from passengers each day so if the surface of money is contaminated how will you know thats why we constantly sanitise our hands sometimes too some passengers are difficult people and if you insist too much that they comply with the protocols they can ignore you or worse refuse to join your car any longer as shown in table 4 when the data are split into sociodemographic and spatial categories all the independent variables scored more than 80 in positive attitudes with no major statistically significant variations as shown in table 4 when the data are split into sociodemographic and spatial categories all the independent variables scored more than 80 in positive attitudes with no major statistically significant variations as shown in table 4 when the data are split into sociodemographic and spatial categories all the independent variables scored more than 80 in positive attitudes with no major statistically significant variations the qualitative interviews shed light on optimistic attitudes toward the covid19 mitigation efforts the open and transparent manner by which the government regularly updated the citizens and the role of faithbased organisations in providing support to its members in times of adversity helped considerably in addition media awareness of the public may be a critical determinant of the hopeful attitudes as seen in the comments below i believe that we are on course to win the battle against the virus i believe in the president of the country and his regular assurances that this one too shall come to pass anytime he comes to update the nation on measures he and his administration are putting up to keep us safe for me my faith in the lord almighty tells me that certainly this devilish pandemic will be overcome at worse it covid19 will become normal like malaria and other diseases that we constantly live with i agree that there has been massive sensitisation in the media initially they were only reporting the case count and deaths here in ghana but when you watch foreign news outlets and you see the plight of corona sufferers in hospitals and also the mass burials of victims i thought the end of the world had come but at least for now it has been a year and we are still alive we give thanks to god and im convinced that we shall overcome assessment of recent practises participants were quizzed on their most current practices such as visiting public places using public transport maintaining hand hygiene and using a face mask during the week preceding the conduct of the field survey while most participants had recently visited public spaces and used commercial transport most wore face masks and ensured that proper hygiene was observed to stay safe figure 5 illustrate the various responses table 5 further shows the results of a chisquare test with regard to the study hypothesis the studys hypothesis was rejected given that the results did not show any statistically significant variations among respondents in washing or sanitising hands persons who had obtained second cycle and tertiary education reported less use of public transport the wearing of facemask was high among all the various groups except respondents who had only completed basic school facemask use in particular was found to be statistically related to the perception of being vulnerable as illustrated in table 6 out of the 967 participants who reportedly wore their facemasks the data show that they did so because they felt that they were at serious risk of receiving the virus an interesting pattern that emerges in the data is that despite socioeconomic and demographic differences among participants compliance to face masking and proper hygienetwo of the most potent mitigation measureswere all above 80 table 5 further shows the results of a chisquare test with regard to the study hypothesis the studys hypothesis was rejected given that the results did not show any statistically significant variations among respondents in washing or sanitising hands persons who had obtained second cycle and tertiary education reported less use of public transport the wearing of facemask was high among all the various groups except respondents who had only completed basic school facemask use in particular was found to be statistically related to the perception of being vulnerable as illustrated in table 6 out of the 967 participants who reportedly wore their facemasks the data show that they did so because they felt that they were at serious risk of receiving the virus in addition findings from the qualitative interviews on participants covid19 perceptions extracted through the analytical lenses of the health belief model are summarised in table 7 the key themes emerged from the dataset border on participants perceived susceptibility to covid19 the severity of sickness the benefits of safe behaviour and barriers to the adoption of mitigation protocols these are also highlighted in the sentiments expressed by participants as follows i consistently wear my facemask i dont joke with it with all that is happening around us and the way people are dying no one should advise you to take precautions especially for some of us who are always in constant contact with strangers passengers i dont think you should allow the government to force you to stay safe as i said earlier on we drivers are vulnerable given the nature of our profession so for me its safety first and besides its mandatory per our companys rules to always mask up whether as passengers or drivers nowadays i dont really wear a face mask to be honest with you for some time now we drivers hang around to chat and even eat together during breaks so far none of my colleagues i know has been found to have contracted the disease so i dont think there is the need to worry ourselves any longer its true that we may all be vulnerable but if youll fall sick or not its not the facemask that can save you the disease only affects the aged and as you can see we are young people moreover it is challenging and uncomfortable to breathe while wearing a facemask personally if a passenger comes on board already masked up why should i bother myself to wear the facemask again the role of the internet in causing some people to become misinformed and subsequently refuse to adhere to the covid19 protocols including masking up was also clearly apparent in the qualitative data i actually dont think wearing the facemask is the remedy to catching the virus my point is that the scientific evidence i have seen suggests that its only persons who have underlying conditions who are the most susceptible to the virus so i think people should rather focus on maintaining a stronger immune system through regular exercise and a good diet i think there are better ways of taking care of ones self at least on social media one can find useful videos and educational materials on how to stay fit and avoid the virus did you know that by inhaling steam from boiled neem leaves azadirachta indica all the viruses can die off even if you become sick check the internet its all there as a matter of fact i think this is a hoax and very soon the truth behind this will come out discussion following the surge in covid19 infections in ghana in march of 2020 the government enforced a stayathome order for nonessential trip makers in the two largest cities of accra and kumasi the government cautiously lifted the monthlong mobility restrictions and announced several enhanced mitigation measures specifically targeting public transport operators such as ridehailing drivers and their passengers ghana like many other african countries was hailed for its effective management of the pandemic 38 in what appears to be a lack of sustained effort to contain the virus ghanas covid19 enviable record was put to the test when on 2 february 2021 official sources cautioned that some 772 new cases had been detected thus raising the total active covid19 cases to 5515 in addition eight new deaths due to covid19 complications were reported therefore increasing the death toll to 424 39 40 41 against this backdrop this paper specifically sought to assess covid19 knowledge levels among drivers their attitudes towards the pandemic and their recent practices deriving from the need to stay safe a major finding made in this paper relates to the high aggregate correct scores obtained by participants on the covid19 knowledge measures with about 84 of participants being knowledgeable about the disease the implication is that information dissemination has gone down well among surveyed participants irrespective of the differences in measurement and scoring systems used in previous studies the overall correct answer rate on covid19 knowledge among ghanaian ridehailing operators is appreciably higher than scores reported in earlier kap studies including among healthcare providers in southwest ethiopia who scored 738 19 and among malaysians who scored 805 15 but certainly lower compared to the 88 and 90 scores obtained respectively among vietnamese health care workers in ho chi minh city 42 and hubei residents in china 29 most participants who scored higher on the covid19 knowledge test in ghana were between 1839 never married and lived in accra the national capital this finding corroborates an earlier study that found higher knowledge scores among young people than other age groups in nigeria and egypt 43 however it contradicts other studies that reported higher knowledge scores for older bangladeshi and malaysian people than for younger participants 1544 in a recent study 8 the extensive media coverage of the pandemic as well as regular televised covid19 updates and personal pleas from the ghanaian president were found to be explanatory factors for the high knowledge of covid19 in the country in addition most of the transport network companies displayed relevant covid19 mitigation information on their apps for the benefit of both drivers and passengers on the requirement to wear facemask over the mouth and nose while riding to always sit in the back seat and also to keep the windows open for proper ventilation it may explain why most drivers were highly knowledgeable about the pandemic however while higher knowledge scores were generally reported some ignorance was observed in the data this is particularly in connection with the origins and transmission questions as many as 534 of participants incorrectly thought that the virus could be transmitted through the consumption or handling of bushmeat this may partly be explained by respondents prior knowledge of the mode of transmission of the western african ebola virus epidemic which was believed to have evolved from the consumption of bats gorillas and duikers again as the pandemic unfolds and scientific knowledge also grows sometimes it may generate some confusion among the populace as to which information is correct or otherwise for example as of 29 march 2020 the world health organization had publicly identified two critical sources for the transmission of the covid19 virus these were transmission between people through respiratory droplets and contact routes the theory of airborne transmission was rejected 45 four months later and based on new evidence the who admitted airborne transmissions together with fomites as some possible routes of infection specifically the airborne transmission was said to occur in indoor and crowded spaces 46 thus it is imperative that as new and better knowledge about the disease is reported extra efforts must be put in place to reeducate ridehailing operators in particular and the public at large to avoid all sorts of confusion the study further found that 604 of surveyed participants scored incorrectly on the governments directive for drivers to write down the contact details of all passengers for possible contact tracing while this was a laudable strategy it seems its implementation was fraught with serious challenges especially for intracity commercial transport operations whereby passengers usually travel over shorter distances thus this directive was mainly ignored and over time most participants forgot that such a directive even existed perhaps policymakers can take a cue from this and make sure to roll out only pragmatic strategies which are also enforceable for effective management of the pandemic a clear case was the governments outright failure to enforce act 1012 strictly which was possibly due to its harshness and the fear of potential backlash from voters especially given that the law was passed in the runup to the 2020 general elections to ensure enforceability authorities may have to amend the law and introduce realistic fines and other community services to deter covid19 offenders concerning participants attitudes towards covid19 most surveyed participants were very frightened about the disease during the first wave when people were less knowledgeable about the symptoms risk factors and mitigation measures during ghanas second wave of infections in early 2021 however the level of anxiety had reduced considerably the implication could be positive in that perhaps the public heeded the pieces of advice not to panic but to comply with the enhanced mitigation measures strictly on the other hand the reduced level of stress about the disease could also imply complacency or outright rejection that the pandemic exists the negative implications of this finding for covid19 case management cannot be overemphasised using the hbm analytical framework some notable observations were made from the qualitative data regarding health beliefs and perceptions of vulnerability to covid19 while many ridehailing drivers had high perceived susceptibility to becoming severely ill with covid19 particularly during ghanas second wave of infections there were some notable perceived barriers to preventative behaviours these include the fact that some colleague drivers were still healthy and had never fallen ill with covid19 and participants perceived themselves to be without any comorbidities this suggests that it is imperative to increase risk perception among drivers as highrisk perception has been found in earlier studies to promote preventive actions including the willingness to become vaccinated against covid19 47 and other influenzalike illnesses 4849 if this is not conducted as found elsewhere reduced susceptibility perceptions among the populace usually lead to complacency and adversely affect preventive behaviour 5051 thankfully as noted in the study most of the participants have high perceptions of the benefits in preventative behaviours such as wearing the facemask which among other benefits makes them feel safe and makes them keep their driving professions as employers were insistent on all employees masking up in addition a majority of drivers agreed that they were vulnerable to infections due to the numerous interactions with passengers and the minimal use of digital payment options on the latter point a recent study 52 found that the virus does not survive at high levels for very long on banknotes a few hours after infection even at high doses the levels and associated risk of infection appear low therefore the health authorities need to provide adequate and accurate information to the public to dispel all forms of misinformation and disinformation which are critical in building trust and confidence in the management of the pandemic as found elsewhere misinformation and disinformation can negatively affect peoples responses to health interventions 5354 so far the evidence suggests that most drivers have positive attitudes toward the covid19 management strategies and are optimistic that the nation will ultimately overcome the pandemic similar to a previous study 15 this finding implies that most peoples trust the information being provided for its consistency and accuracy and are most likely to comply for their safety and that of their loved ones this has been found in a recent brazilian study which concluded that confidence in the capability of social institutions significantly translates into the adoption or otherwise of recommended protective behaviours 55 the study also found that drivers who reported optimistic attitudes and perceived themselves as at high risk of infection reported wearing face masks consistently and practising proper hand hygiene unfortunately as found in this present study some participants who agreed that their profession significantly exposed them to the outbreak surprisingly indicated that they never consistently wore face masks when they went outdoors this finding lends credence to an earlier ghanaian study among commercial drivers 8 which reported that most drivers wore face masks and there were others who reportedly never wore face masks this is because the virus no longer posed any significant threat to their lives and that face mask use was associated with discomfort finally they were spiritually fortified against infection against this backdrop this study presents yet another disturbing piece of evidence that should arouse the interest of relevant policymakers to intensify the ongoing public health education especially among drivers as in all studies this present study must be read with some limitations in mind at the time of conducting the survey the research instrument which specifically measured the kap of participants was not designed using the health belief model questionnaire format instead the philosophical underpinnings of the hbm were adopted as an appealing analytical framework for making sense of the qualitative dataset future studies may take a cue from earlier studies 47 48 49 which adopted the hbm questionnaire format to frame the questions before the field investigations conclusions we assessed the knowledge attitudes and practices of ridehailing operators in ghana regarding the ongoing covid19 pandemic we found that knowledge levels about the disease are relatively high among surveyed drivers most of them have a hopeful attitude towards the mitigation measures adopted to curtail community spread global and national efforts to sensitise people and enforcing rules and regulations have played a significant role in producing the positive outcomes shown by this study the role of the media has been critical in both educating and instilling fear in people 20 given that public transport could promote the spread of the disease it is understandable why efforts and achievements have been higher in this area persuasion alone is not enough to cause people to change their attitudes during pandemics as shown in the ghanaian case where police military and local government security personnel physically sanctioned offenders of protocols certainly sociodemographic variables are essential in understanding differences in the uptake of information and instructions changing attitudes and influencing others however in pandemic situations the states role in creating this awareness and enforcing new norms is paramount therefore weak states with poor capacities may achieve less in imparting new knowledge and engendering the uptake of appropriate practices through the enforcement of laid down protocols given that full compliance to the established mitigation measures is yet to be achieved the authorities need to pursue targeted interventions and health campaigns to further enhance knowledge about the pandemic to engender preventive behaviour among the populace informed consent statement informed consent was obtained from all participants involved in the study the ech approved our proposal to seek the verbal and written consent of participants in the study this study was not a sensitive one and did not pose any specific material risk to survey participants who were all adults and were not vulnerable we adequately explained the study to survey participants including their rights and benefits data availability statement the data presented in this study are available on request from the corresponding author

since its outbreak health authorities have launched vigorous covid19 health promotion campaigns this study assesses ridehailing operators covid19 knowledge attitudes and practices in ghana with the aim of engendering precautionary behaviour among the populace a complementary mixed methods approach was adopted this involved a crosssectional survey of 1014 participants who were also allowed to share their covid19related lived experiences qualitatively after successfully completing the survey the aggregate correct knowledge score was 84 most respondents were frightful of the virus 96 but the majority had faith in the covid19 protocols 87 thus most participants reported high use of face masks 95 and practise personal hygiene 92 however social media misinformation and the subsequent complacency have dissuaded some participants from complying with the safety protocols the qualitative data also show evidence of high susceptibility to covid19 the perceived benefits of safe behaviour including masking up were equally high among drivers surveyed albeit barriers to preventative behaviours remain rife therefore this study emphasises the importance of sustaining and improving public awareness by highlighting the susceptibility of all demographic groups to the virus and the need to counteract misinformation on social media

introduction mental health difficulties affect between 10 to 20 of children globally 12 for many children these difficulties first emerge in the early years 3 during which the brain is highly sensitive to nurturing environments and stimulating interactions with caregivers 4 young childrens mental health during the first decade of life forms a foundation for their mental health and social functioning throughout the life course and is therefore critical to strategies aimed at promoting mental health at a population level 5 in the early years mental health difficulties are often conceptualised according to externalising difficulties and internalising difficulties 6 mental health competence in early childhood includes psychosocial skills such as regulating emotions and behaviour skills in interacting with peers and caring for others 78 evidence suggests that both mental health difficulties and competence carry implications for important health and social outcomes such as young childrens capacity to engage with early learning experiences 9 10 11 bioecological models recognise that childrens mental health is influenced by multiple contexts in which children develop including the neighbourhood as well as the family and wider societal contexts 12 it has long been observed that neighbourhoods matter to young childrens mental health and this is welldocumented in the neighbourhood effects literature 1314 for example children growing up in disadvantaged neighbourhoods are more likely to demonstrate mental health difficultiesirrespective of their individual family circumstancescompared with their peers in more advantaged neighbourhoods 15 however these neighbourhood effects are still largely regarded as a black box prompting calls for a deeper understanding of the specific neighbourhoodlevel factorsespecially those that are modifiable by policy and planning interventionsthat support better mental health in early childhood 14 such identification of specific modifiable neighbourhood features could enable a promising opportunity to promote child mental health at a population level as neighbourhoodlevel interventions have the benefit of reaching large numbers of children and their families one key feature of a supportive neighbourhood for children is the availability and quality of neighbourhood public open space highquality public open space provides opportunities for play and stimulating activities socialisation and skillbuilding 16 it seems likely that these experiences play a role in promoting childrens mental health qualitative research with young childrens caregivers points to public open space as a key community asset that families regard as important for young childrens development and skillbuilding 17 it has also been theorised that green spacepublic open space with natural features may have a psychologically restorative or protective effect helping to reduce or prevent mental distress 18 in older children several studies have found a protective relationship between exposure to green space and reduced mental health difficulties particularly hyperactivity and inattention 19 20 21 22 not all parks are created equal however with some evidence indicating that the quality of public open space makes a difference for example some studies have found more consistent or larger magnitude of associations between young childrens mental health and measures of quality of public open space versus measures of quantity or proximity 23 24 25 from a childand familycentred perspective highquality public open space includes features supporting play and recreation as well as facilities that enable families to use the space over the course of several hours 17 despite the plausibility of the relationship between early childhood mental health and public open space access and quality the evidence base is nascent recent systematic reviews of the evidence around public open space and child mental health have identified a lack of studies investigating associations with mental health in the early childhood period and mental health competence in particular 2627 furthermore very few studies have examined the quality of public open space and how this relates to young childrens mental health 2627 this gap exists despite a growing body of evidence suggesting the importance of public open space quality in particular for promoting mental health for example a study conducted with adults in australia found that those with access to highquality public open space were around two times more likely to have low psychological distress than those with access to lowquality public open space 28 the authors of another study found that positive mental health was associated with specific quality features of public open space with the largest effect size observed for sporting features 29 in addition to these gaps a major limitation of the current evidence is a lack of studies attempting to unpack how specific neighbourhood attributes relate to childrens experiences of disadvantage 26 inequity between neighbourhoods in terms of the resources and opportunities provided to young children and families has been postulated as a potential mechanism through which neighbourhood effects on childrens early mental health are transmitted with children living in the most disadvantaged neighbourhoods having fewer opportunities to build social and emotional skills 1430 internationally studies examining the relationships between neighbourhood disadvantage and public open space availability and quality have reported somewhat mixed findings across different countries and contexts but there is some suggestion that those living in the most disadvantaged neighbourhoods may have worse access to and poorer quality of local public open space than their peers in more affluent neighbourhoods 31 32 33 research examining how access and quality of neighbourhood public open space relates to young childrens experiences of disadvantage is urgently needed given evidence that children facing disadvantage experience a double burden of higher mental health difficulties and lower mental health competence compared with their more advantaged peers 34 35 36 data linkage offers new ways of answering these questions and clarifying associations across large numbers of children and potentially entire populations of children previous data linkage of early child development outcomes and built environment measures have successfully generated evidence for individual australian cities 2437 the present study extends this work by leveraging a globally unique population linked dataset combining geographic and objective data on childrens neighbourhoodbuilt environments with data collected as part of the australian early development census a population census of early child development across australias eight capital cities the aim of this study is to document access to public open space in a national cohort of children and describe how this access varies between relatively socioeconomically advantaged and disadvantaged children examine relationships between access to and quality of neighbourhood public open space and mental health in early childhood and investigate whether these relationships differ among children by socioeconomic disadvantage in doing so we aimed to inform urban planning and policy as well as early childhood and education portfolios by developing the evidence base around what neighbourhood characteristics can be modified at scale to support mental health in the early years materials and methods study design australian early development censusbuilt environment this study uses a crosssectional population linked dataset the australian early development censusbuilt environment dataset which combines child demographics and developmental outcomes collected as part of the australian early development census in 2015 geographic data and objective measurements of childrens neighbourhood built environments we provide a detailed description of this data in another article of this special issue 38 details of each of these component datasets and data linkage procedures are described further below australian early development census every three years the australian government funds a population census of childrens early development the australian early development census the aedc provides a snapshot of child development for all children across australia who are entering their first year of fulltime schooling teachers complete the instrument an adapted version of the canadian early development index 39 for each child in their class responding to a range of items encompassing physical health and wellbeing social competence emotional maturity language cognitive skills communication skills and general knowledge 40 the aedcs exceptional population coverage is achieved through a range of strategies such as its use of secure webbased data entry system and funding to cover teacher relief 4142 geographic and neighbourhood built environment data objective neighbourhoodbuilt environment measures were developed for australias most populous 21 cities 43 these measures formed part of a preexisting database used to calculate national parcellevel liveability indicators across australia 44 these measures along with geospatially referenced 2016 australian census data were linked to unique home addresses of children from the 2015 aedc this process involved matching childrens home addresses to the nearest sampling point location in the national database sampling point locations which served as proxies for residential lots were derived from the geocoded national address file australias authoritative national address database produced and maintained by geoscape australia 44 45 46 a detailed description of sampling point methodology is presented elsewhere 4445 over 80 spatial measures of the neighbourhood environment were calculated for each child including information about the public open space available around the childs home and the attributes of these spaces these measures were developed and conceptualised as part of the child liveability work programs in the centre for urban research at rmit university and murdoch childrens research institute 384748 given that these spatial measures were conceptualised for urban areas children living in remote or very remote locations were not included in the linked aedcbe dataset study participants in total 302003 children participated in the aedc in 2015 of which 235631 children resided in 21 of australias most populous cities and towns and were included in the aedcbe linked dataset the present analysis focuses on australias capital cities school entrant population including 199200 children living in adelaide brisbane canberra darwin hobart melbourne perth and sydney we focused on capital cities as a starting point for building this evidence base because we expected that relationships with mental health might differ in rural and regional towns and require focused exploration australias eight capital cities are diverse yet they are unified in that they represent the major metropolitan centre of each state or territory data linkage procedures the data linkage procedures and geospatial measures included in the aedcbe dataset are presented in detail elsewhere 3848 briefly the aedc data custodians the social research centre provided geocoded addresses of 2015 aedc participants as well as child demographics and development data to the australian institute of family studies an approved data linkage body aifs provided rmit university with a deidentified aedc participant list of geocoded addresses including an additional 5 of false addresses to help ensure anonymity the spatial measures of childrens neighbourhood environment were calculated and attached to the participant list and returned to aifs who removed the false addresses deidentified the final linked dataset by removing the geocoded addresses and integrated the spatial neighbourhood environment measures with aedc content data the final deidentified linked dataset was then provided to the research team for analysis data linkage was undertaken by aifs in august 2019 mental health measures measures of each mental health outcome have been previously conceptualised and derived from the aedc these indicators are developmentally appropriate for early childhood and have been validated against the strengths and difficulties questionnaire 710353649 teachers reported on childrens demonstration of behaviours and skills using likert scales or binary scales for each mental health outcome the average score of the relevant aedc subdomains was calculated for each child as is the case for other domains of the aedc all three of the outcomes examined here had a strongly skewed distribution and were therefore dichotomized as is recommended for other aedc domains 40 cutpoints for dichotomisation used the bottom tertile for difficulties or competencies following previous research 10 and were the same as the cutpoints based on the distribution of scores in the entire aedcbe national cohort facilitating future comparisons between the eight capital cities of focus in this study and the broader urban child population in australia externalising difficulties externalising difficulties were indicated by teacher reports on the aedc subdomains of hyperactivity and inattentiveness and aggressive behaviours this measure was dichotomised using the first tertile as a cut point with children in the poorest scoring tertile being classified as demonstrating high difficulties internalising difficulties internalising difficulties were indicated by teacherreported items from the anxious or fearful behaviours aedc subdomain 10 this measure was dichotomized into high and low difficulties in the same way as externalising difficulties competence the competence measure includes teacher reported skills of overall social competence approaches to learning readiness to explore new things prosocial and helping behaviour this measure was dichotomised at the top tertile such that children with the most exceptional strengths were classified as demonstrating high competence public open space measures data for the public open space measures in the aedcbe dataset were sourced from openstreetmap in 2018 50 openstreetmap is a community contributed opensource database cataloguing spatial neighbourhood data 50 a major strength is its consistency across the eight capital cities given that at the time of data linkage there was not an existing national database of public open space in australia detailed information on the types of land uses and space included and excluded in the studys definitions of public open space and the operationalization of these using openstreetmap are presented in supplementary materials and additional metadata can be found in the australian urban observatory 51 each of the public open space access measures were derived from continuous variables measuring the distance in metres along the road network from a childs home to the nearest child friendly public open space with both a playground and a toilet nearby or public open space of other types but lacking these child friendly features detailed information about the construction of these spatial measures is presented in the supplementary materials and developed following guidance from lamb and colleagues 52 the definition of child friendly public open space was based on qualitative research with caregivers of young children across australia which pointed to the salience of these two quality features as especially important for supporting young families use of public open space 17 to facilitate their interpretation in terms of tangible policies and interventions public open space measures were categorised into three mutually exclusive groups to indicate both access and quality within two distance thresholds 400 metres and 800 metres these distances were chosen based on the previous child health literature 27 and current australian policy standards for public open space provision 5354 for example although little is known about the size of the areas within their neighbourhoods where young children roam previous australian research suggests that on average caregivers perceive 15 km to be an appropriate walking distance for young children 55 which aligns closely with an 800 m oneway walking distance demographic measures demographic measures were drawn from the aedc almost all of which were prepopulated from information collected through school enrolment processes except for one teacherreported item assessing english proficiency these measures represent markers of exposure to structural inequities and therefore are likely to be associated with both exposure and mental health outcomes maternal education maternal education was based on the highest level of schooling and highest postschool qualification by the caregiver listed as parent 1 for the child australian data shows that parent 1 is almost always the childs biological mother 5657 three groups were derived to cover high middle and low maternal education groups in the australian context bachelors degree or higher completed high school andor other tertiary postschool qualification did not complete high school sex a dichotomous measure of the childs sex was included to account for any sexspecific differences in mental health indigenous status a dichotomous measure was used the aim of including this measure was to factor into analysis the historical and contemporary impacts of colonization and systemic racism that children and families from indigenous backgrounds in australia continue to face but which is rarely captured in administrative data sources 58 language background and english proficiency this study used a measure of language background and english proficiency developed by goldfeld and colleagues 59 which was based on one prepopulated item from the aedc indicating language background other than english and one teacherreported item assessing english proficiency of the child from these two pieces of information three groups were derived english only multilingual multilingual englishproficient was defined as any child who was rated by their teacher as having average or goodtovery good english proficiency this measure was included in the analysis to account for the marginalisation and social exclusion that is often experienced by children and families from diverse cultural and linguistic backgrounds including in the classroom given english is the dominant language of instruction in australia additional health and education needs a dichotomous measure indicating whether the child was identified as having additional health and education needs was included children were identified as having additional health and education needs if they had a medical diagnosis of a chronic medical physical or intellectually disabling condition that requires special assistance 60 this measure was included to account for the barriers these children face in participating in the opportunities that build mental health which result in higher risk of mental health difficulties 29 contextual measures 291 neighbourhood boundaries neighbourhood geographic boundaries were approximated in this study using the australian bureau of statistics statistical area 1 which represents a small area with a population size of approximately 400 people 61 neighbourhood disadvantage neighbourhood disadvantage was measured at the sa1 using the australian bureau of statistics socioeconomic index for areasindex of relative socioeconomic disadvantage 62 this commonly used multidimensional index captures multiple aspects of an areas disadvantage such as proportion of residents on low incomes proportion of residents without internet access 62 neighbourhood disadvantage quintiles were calculated by the australian bureau of statistics for all sa1s in australia prior to data linkage hence neighbourhood disadvantage quintiles represent the socioeconomic characteristics of a neighbourhood relative to all other neighbourhoods across australia the use of quantiles is recommended by the australian bureau of statistics 62 and seifairsd quintiles are commonly reported on and used in analyses of data from the aedc eg 24356063 capital city of residence capital city boundaries were defined using the australian bureau of statistics greater capital city statistical areas which are intended to capture the functional extent of a capital city 61 rather than capturing the builtup edge of the city each gccsa reflects a more nuanced understanding of urban areas including people who live in nearby towns but regularly work shop or visit the capital city 61 statistical analysis first a descriptive picture of the entire capital cities cohort was generated including cohort characteristics expressed as a percentage as well as the characteristics of children with friendly public open space were calculated and displayed visually these percentages were also calculated and graphed separately within each of the neighbourhood disadvantage quintiles descriptive statistics were calculated in stata 16 64 statistical analysis was informed by a directed acyclic graph presented in supplementary materials a multilevel modelling approach was used to account for the nonindependence of childrens mental health outcomes within neighbourhoods first univariate multilevel logistic regression models were used to estimate the unadjusted association between each public open space exposure measure and the odds of each mental health outcome these associations were modelled separately for each of the four exposures and by each of the three outcomes resulting in a total of 12 models multivariable multilevel logistic regression models were used to estimate the adjusted associations based on the directed acyclic graph we identified two sets of adjustment variables aligning to two different assumptions about the underlying causal pathways between neighbourhood disadvantage public open space access by type and childrens mental health the first assumption is that there is systematic underinvestment in public open space in disadvantaged neighbourhoods alternatively the second assumption is that provision of public open space drives up property values leading to gentrification displacement of disadvantaged residents and reduction in neighbourhood disadvantage the first set of adjustment variables included childand familylevel demographic characteristics only the second included these demographic characteristics as well as neighbourhood disadvantage both adjustment sets were modelled all models were estimated using markov chain monte carlo estimation procedures using mlwin and stata 16s runmlwin command 6566 model convergence was checked by visually examining trace plots generated in mlwin for models a and b a chain length of 35000 and burnin of 2000 iterations was used model c was run with a burnin of 5000 iterations and chain lengths of 35000 and 50000 sensitivity analysis to assess whether associations were different within each capital city we aimed to undertake a sensitivity analysis models a b and c were run using the same procedures outlined above with children stratified by capital city however the stratified results were not able to be reliably estimated due to issues with model convergence for models b and c hence we present results for the entire capital cities cohort and can only speculate on cityspecific associations with full adjustment missing data aedc has exceptional population coverage with only 1 missing data on average across study variables included in this analysis hence analysis focused on children with complete data across all study variables including measures of neighbourhood disadvantage covariates and each mental health outcome due to differences in the numbers of children with missing data across the three outcomes this resulted in slightly different numbers of children included in each analysis detailed information on missing data is presented in supplementary materials ethics approval approvals from the royal childrens hospital human research ethics committee rmit university hrec aedc data custodians and the authorised data linkage agency were obtained for this project results aedcbe cohort characteristics demographic characteristics of the children included in the aedcbe capital cities cohort are presented in table 1 the capital cities cohort was 487 female over onequarter of the children in this cohort had a multilingual language background a slightly higher proportion than in the overall 2015 aedc national cohort 60 a lower proportion of aboriginal and torres strait islander children lived in these eight capital cities as compared with the national cohort which includes regional towns and remote areas 60 a substantial proportion of children in this cohort were from universityeducated families and from australias least disadvantaged neighbourhoods this is higher than the proportion of children who live in the least disadvantaged neighbourhoods in the national cohort 60 inequities in access to public open space overall access to any type of public open space was high 95 of the cohort had access to a public open space within 800 m from home along the road network and over 75 had access within 400 m however several subgroups of children were disproportionately represented in the groups without access for example despite making up only 28 of the overall capital cities cohort aboriginal and torres strait islander children accounted for 39 of children without access to any public open space within 800 m as shown in table 1 there were also several subgroups of children who were disproportionately underrepresented in the optimal public open space exposure group this was apparent at both the 800 m and 400 m distance thresholds for example despite making up 113 of the capital cities cohort children in the lowest maternal education group made up only 89 and 86 of the children with access to child friendly public open space within 800 m and 400 m respectively similarly 159 of the children in the capital cities cohort lived in the most disadvantaged neighbourhoods but these children represented only 135 and 125 of the child friendly public open space exposure group these results illustrate systemic inequities in the provision of public resources that support health and wellbeing descriptive statistics computed separately for each capital city showed that the distribution of children from different demographics and maternal education groupings across each of the public open space exposure groups was similar to the nationallevel descriptive statistics shown in table 1 an exception to this was the relationship between neighbourhood disadvantage and the public open space exposure groups for example in adelaide canberra and melbourne children from the least disadvantaged neighbourhoods were overrepresented in the group with no access to public open space within 800 m whereas in hobart and brisbane children living in the most disadvantaged neighbourhoods were overrepresented in the group with no access to public open space furthermore as shown in figure 1 the percentages of children with access to public open space varied across the maternal education subgroups this gradient in access was most striking when examining access to child friendly public open space for example in terms of the percentage of children with access to a child friendly public open space within 800 m from home there was a 12and 16percentage point difference between children in the highest maternal education group and those in the middle and lowest maternal education groups respectively a similar gradient was evident at the 400 m distance threshold similarly figure 2 shows a gradient in access to child friendly public open space across quintiles of neighbourhood disadvantage for example in terms of access to a child friendly public open space within 800 m from home there was a 12 percentagepoint difference between the least and most disadvantaged neighbourhoods with the latter having poorer access these differences were not just between the most and least disadvantaged neighbourhoods but rather they were illustrative of a gradient cutting across all five quintiles where each quintile of disadvantage corresponded with a step down in the percentage of children with access to child friendly public open space at both the 800 m and 400 m distance thresholds when examining access within 800 m a large percentage of children living in the most disadvantaged neighbourhoods had access to some type of public open space but this was more likely to be nonchild friendly types of open space associations between public open space and child mental health results from the twolevel unadjusted logistic regression model and the twolevel models adjusted for childand family levelcharacteristics only and child family and neighbourhoodlevel factors are presented for the full capital cities cohort in table 2 and figure 3 unadjusted associations were in the hypothesised direction for all exposures and outcomes furthermore across all public open space exposures and outcomes unadjusted associations indicated that children with access to a child friendly public open space had lower odds of difficulties and higher odds of competence than those who had access to nonchild friendly types of public open space these associations are attenuated somewhat in models b and c which adjust for different confounder sets for each of the three mental health outcomes models b and c yielded similar results meaning that the theoretical assumptions about the nature of the causal relationship between neighbourhood disadvantage and public open space access did not have a material impact on the findings across all three outcomes examined and all three adjustment sets larger associations were observed between childrens mental health and public open space access within 800 m rather than the 400 m distance threshold unadjusted associations indicated that children with access to public open space had better mental health and the magnitude of association was larger if the public open space had child friendly features unadjusted associations were smallest in magnitude for childrens internalising difficulties in general the associations attenuated after adjusting for child family and neighbourhoodlevel factors for externalising and internalising difficulties after adjustment the association with child friendly public open space was similar to the association with nonchild friendly public open space for childrens competence after adjusting for confounders in models b and c results were more suggestive of an additional benefit of child friendly features the magnitude of association for child friendly public open space remained slightly larger than the magnitude of association for nonchild friendly public open space within 800 m this patterning was similar though less distinct at the 400 m distance threshold effect modification by maternal education tables 3 and4 show the results of the effect modification analysis these results are presented in a tabular format developed by knol and vanderweele for presenting the results of investigations into effect modification 67 notes all models adjusted for childs sex language background and english proficiency aboriginal and torres strait islander background additional health and education needs neighbourhood disadvantage adjusted odds ratios and credible intervals presented in the first three columns within each education level were calculated separately for each maternal education group with distinct reference categories for each maternal education group aor adjusted odds ratio 95 cri 95 credible interval pos public open space measures of effect modification all measures of effect modification were calculated as a ratio of odds ratios with the denominator being the odds ratio for the highest maternal education group measures of effect modification externalising difficulties nonchild friendly pos and middle maternal education group 099 child friendly pos and middle maternal education group 101 nonchild friendly pos and lowest maternal education group 095 child friendly pos and lowest maternal education group 089 measures of effect modification internalising difficulties nonchild friendly pos and middle maternal education group 102 child friendly pos and middle maternal education group 107 nonchild friendly pos and lowest maternal education group 111 child friendly pos and lowest maternal education group 119 measures of effect modification competence nonchild friendly pos and middle maternal education group 103 child friendly pos and middle maternal education group 097 nonchild friendly pos and lowest maternal education group 094 child friendly pos and lowest maternal education group 087 notes all models adjusted for childs sex language background and english proficiency aboriginal and torres strait islander background additional health and education needs neighbourhood disadvantage adjusted odds ratios and credible intervals presented in the first three columns within each education level were calculated separately for each maternal education group with distinct reference categories for each maternal education group aor adjusted odds ratio 95 cri 95 credible interval pos public open space measures of effect modification all measures of effect modification were calculated as a ratio of odds ratios with the denominator being the odds ratio for the highest maternal education group measures of effect modification externalising difficulties nonchild friendly pos and middle maternal education group 097 child friendly pos and middle maternal education group 098 nonchild friendly pos and lowest maternal education group 101 child friendly pos and lowest maternal education group 091 measures of effect modification internalising difficulties nonchild friendly pos and middle maternal education group 098 child friendly pos and middle maternal education group 102 nonchild friendly pos and lowest maternal education group 100 child friendly pos and lowest maternal education group 110 measures of effect modification competence nonchild friendly pos and middle maternal education group 103 child friendly pos and middle maternal education group 105 nonchild friendly pos and lowest maternal education group 099 child friendly pos and lowest maternal education group 097 overall there was weaktomoderate evidence of effect modification by maternal education on the association between childrens mental health and access to public open space looking across all three mental health outcomes and each of the public open space exposure measures differences in the magnitude or direction of association were most evident for children in the lowest maternal education group than for those in the middle group and when examining access to child friendly public open space in some instances associations appeared larger for children in the lowest education group whereas in other instances the associations were smaller or in the oppositethananticipated direction for this group of children regarding childrens externalising difficulties stratumspecific adjusted odds ratios provided weaktomoderate evidence that children in the lowest maternal education group may especially benefit from living within 800 m of child friendly public open space compared with their peers from the middle and high education groups who had child friendly public open space access this aligned with the hypothesised patterning of effect modification for example children in the lowest maternal education group had 17 lower odds of demonstrating externalising difficulties if they had access to a child friendly public open space within 800 m versus no access to public open space in the middle and highest maternal education groups the association appeared to be smaller with children having 6 and 7 reduced odds of externalising difficulties respectively if they had access to a child friendly public open space within 800 m compared with no access to public open space the measure of effect modification for the lowest maternal education group with access to child friendly public open space provided weaktomoderate evidence to support this a somewhat similar pattern was observed for externalising difficulties and public open space access at the 400 m distance threshold however stratumspecific measures of association between externalising difficulties and each of the public open space exposures at 400 m were consistent with no association within all maternal education groups in terms of childrens internalising difficulties and competence there was weaker evidence of effect modification and this patterning was in the oppositethananticipated direction for internalising difficulties children in the lowest maternal education group were observed to have higher likelihood of internalising difficulties if they lived within 800 m of child friendly public open space compared with those without access to public open space whereas their peers in the middle and highest education groups had a lower likelihood of demonstrating internalising difficulties if they had access compared with those who did not the measure of effect modification for the lowest maternal education group with access to child friendly public open space within 800 m provided weaktomoderate evidence to support this and similar patterning was observed for public open space access within 400 m for childrens competence results showed that children in the middle and highest maternal education groups who had access to either type of public open space within 800 m had higher odds of demonstrating high competence than those who did not have access to any public open space however children in the lowest maternal education group who lived within 800 m of these spaces did not appear to receive the same benefit the measure of effect modification for the lowest maternal education group with access to child friendly public open space provided weaktomoderate evidence to support this patterning at the 400 m distance threshold however results generally appeared similar across the maternal education groups with small associations observed in the middle education group only discussion this study examined associations between multiple measures of public open space access including qualityrelated measures and a comprehensive assessment of childrens mental health across a population of over 150000 schoolentry aged children residing in australias eight capital cities we also examined how access to and quality of public open space is distributed along subgroups of children inequities in access to public open space across capital cities cohort our results indicate that access to child friendly public open space is not randomly distributed but follows a social gradient cutting across both family socioeconomic position and neighbourhood disadvantage quintiles with each step up in neighbourhood disadvantage the percentage of children with access to child friendly public open space within the specified distances was incrementally lower this inequitable distribution aligns with previous australian findings 31 furthermore we found evidence that aboriginal and torres strait islander children were overrepresented in the group without access to child friendly public open space within 800 m these differences represent systemic inequities in provision of healthsupporting resources addressing these inequities should be prioritised as part of australias commitments to the un convention on the rights of the child and the sustainable development goals which call for access to green and public spaces for all 68 it is likely that the social gradient in public open space access and quality relates to the spatial distribution of disadvantage across cities which is influenced by housing affordability and processes like gentrification 69 for example in australias capital cities there is a shortage of affordable housing located in the inner ring as a result families facing socioeconomic disadvantage tend to be overrepresented in two types of neighbourhoods ageing middle ring higherdensity neighbourhoods and lowdensity outer suburban neighbourhoods 70 public open space provision may also drive increases in property values and housing costs leading to gentrification and the displacement of families facing socioeconomic disadvantage 7172 understanding how these processes are unfolding in australian cities will be critical to informing strategies to improve urban liveability for example some advocate for making cities just green enough without exacerbating gentrification 33 recent scholarship on the liveability of australias cities calls for action across several domains including improving housing affordability as well as access to highquality public open space 44 public open space access as a protective and promotive factor at a national level we found evidence of protective associations between public open space access and the development of mental health difficulties in this capital cities cohort our analysis found that access to public open space was associated with lower odds of externalising difficulties and marginally lower odds of internalising difficulties in the early years this aligns with findings from previous studies conducted in australia as well as north american and european studies 23 73 74 75 the national pooled estimates indicated a similar benefit for public open space with child friendly features and public open space of other types other australian studies focusing on the city of perth have observed that access to public open space of higher quality or attractiveness appears more important to childrens early social development than access to public open space in general whereas no association was detected with emotional development 2437 the difference in findings may be due to the use of outcomes which capture somewhat different aspects of mental health difficulties or the different measure of public open space quality we also found some evidence of an association between public open space access and childrens competence suggesting this exposure may also be a promotive factor nationally the association was larger in magnitude for public open space with child friendly features than for those lacking these features this finding was consistent with the theoretical framing of this study which hypothesised that access to child friendly public open space with features that support extended use by families provides a key neighbourhood opportunity for skillbuilding and socialisation during early years it adds to the growing evidence base concerning the importance of public open space for building childrens competence 26 and the importance of public open space quality in particular 2324 for promoting mental health during early years our results showed larger magnitudes of association between child mental health and public open space access when access was defined using the larger distance threshold of 800 m previous studies testing associations between health outcomes and the built environment using multiple distance thresholds have also noted larger effect sizes for larger distances 76 the stratified analysis also showed greater consistency of associations when access was defined using 800 m as a threshold this supports the notion that families in australias capital cities may be willing to travel further distances even when children are young to reach more desirable destinations for whom does access matter most associations within maternal education groups overall we found weaktomoderate evidence of effect modification across the maternal education groups which suggests that access matters similarly for all children but more research in this area is needed to clarify the nature of these associations the results here partly align with findings from two previous studies from lithuania and the united kingdom respectively which observed that for children in the lowest maternal education group living closer to public open space 77 or in areas with a higher percentage of natural space 78 was associated with fewer externalising difficulties however these same studies found that these measures of public open space were also associated with more prosocial behaviour in contrast with the results here our results suggested that children in the lowest maternal education subgroup did not benefit as much from public open space access in terms of their competence as compared with children in the middle and high maternal education subgroups our results also contrast with a previous study from the united kingdom that found that children in the lowest socioeconomic group living in areas with a higher percentage of green space was associated with fewer internalising difficulties 79 whereas the results here found oppositethananticipated association with higher odds of internalising difficulties for this subgroup of children these conflicting findings could be due to several potential reasons including different outcome measures used the studies being conducted in different countries or other contextual factors there may be additional quality features of public open space beyond those measured here that matter for building competence and reducing odds of internalising difficulties it is also likely that other neighbourhoodlevel factors intersect with public open space quality to influence families likelihood of using these spaces as well as the level of social activity in these spaces finally the divergent findings could be the result of unmeasured confounding in the present study given that we were not able to account for other aspects of socioeconomic position which may impact on where families live independently of maternal education similarities and differences between distinct capital cities although the national results were illustrative of a social gradient in public open space access across neighbourhood disadvantage quintiles we found that in some cities the relationship between neighbourhood disadvantage and public open space access was less straightforward it is possible that other contextual factors such as the urban form location of affordable housing in relation to the city centre or city size also play into the neighbourhood disadvantagepublic open space access relationship in different ways for each capital city strengths of this study a major strength of this study is its use of a unique population dataset the aedcbe dataset which is inclusive of all children entering the first year of school in australias capital cities reducing potential for selection bias which is particularly critical given the focus on children from disadvantaged backgrounds who are otherwise typically underrepresented in samples the aedcbe dataset includes valuable information about childrens socioeconomic and demographic backgrounds and neighbourhood environments to our knowledge this is the first time such a linked population dataset has been made available internationally furthermore the use of validated theoretically established measures of competence externalising and internalising difficulties 7103536 was a key strength to reduce measurement bias limitations the results of this study should be viewed in the light of some limitations we theorised a causal relationship between access to child friendly public open space and early childhood mental health but there are limitations to the extent to which our results can provide evidence of this for example this study was a crosssectional analysis so we cannot rule out reverse causation despite the inclusion of important demographics our analysis was not able to account for certain familylevel factors caregivers perceptions of neighbourhood safety or information on families actual usage of public open space in addition maternal education is only one aspect of family socioeconomic position which is a multidimensional construct and includes other factors like household income 80 these unmeasured factorsand those pertaining to family socioeconomic positions in particularare likely to be important sources of confounding of the relationship between public open space access and child mental health it is possible that our results overestimate the true magnitude of association given the inequitable patterning of public open space access and known impacts of socioeconomic position on mental health this study used an administrative geographic unit to measure the concept of neighbourhood disadvantage which may not necessarily align with time spent in the neighbourhood this may introduce bias through measurement error leading to an underestimation of the true magnitude of confounding by neighbourhood disadvantage finally our definition of public open space quality was based on qualitative research conducted with families with young children across australia 17 who stressed these two features were critical determinants of families usage of these spaces however there are likely other quality features that further encourage use of these public open spaces such as vegetation and tree coverage amenities and safety future research could more deeply explore the features that encourage or determine families use of these spaces using both quantitative and qualitative techniques to inform more childand familycentred urban planning and design guidelines implications and directions for future research our findings represent a first look at how public open space access and child friendliness across australias capital cities relates to childrens mental health in their early years although our findings in the unadjusted analyses were consistent with the hypothesised direction across all outcomes and for both public open space exposure groups the stratified analyses revealed some variation across cities that requires further unpacking several directions for future research are needed to enhance understandings of how public open space relates to young childrens mental health first future quantitative analyses drawing on longitudinal data ideally with detailed information on families socioeconomic circumstances will be critical to unpacking the causal relationships between disadvantage public open space access and quality and childrens mental health in distinct australian cities as well as internationally as mentioned earlier research on factors influencing public open space use and quality aspects relevant to families with young children will be important for triangulating findings in particular qualitative studies are needed that focus on the neighbourhood features that might promote young childrens competence specifically and especially among families experiencing disadvantage lastly urban scholarship unpacking the processes of gentrification and housing affordability and how this relates to the distribution of child friendly public open space in diverse australian cities and towns will be important to informing urban planning and policy responses and redressing inequities conclusions this study examined access to and quality of public open space and young childrens mental health across eight australian capital cities using a unique population linked dataset the australian early development censusbuilt environment a gradient in access to child friendly public open space was detected with children facing disadvantage having incrementally poorer access with each step down the socioeconomic ladder this is of concern given that children with access to public open space close to home were also found to have a lower likelihood of demonstrating externalising and internalising difficulties and higher likelihood of demonstrating competence furthermore we found weaktomoderate evidence that these associations might be different in children from lower socioeconomic backgrounds further research is needed to clarify these potential differences including qualitative research with children and families into the factors influencing public open space use and the quality features most salient for building childrens competence addressing inequities in child mental health requires multisectoral action together findings from this study suggest that reducing inequities in access to neighbourhood resources including child friendly public open space should be included as part of a multifaceted strategy to improve mental health in early childhood supplementary materials the following supporting information can be downloaded at figure s1 directed acyclic graph used to develop the analysis plan table s1 description of public open space access and quality measures based on guidance developed by lamb and colleagues 52 table s2 missing data across study variables table s3 adelaide cohort characteristics and demographic characteristics of children in each public open space access group table s4 brisbane cohort characteristics and demographic characteristics of children in each public open space access group table s5 canberra cohort characteristics and demographic characteristics of children in each public open space access group table s6 darwin cohort characteristics and demographic characteristics of children in each public open space access group table s7 hobart cohort characteristics and demographic characteristics of children in each public open space access group table s8 melbourne cohort characteristics and demographic characteristics of children in each public open space access group table s9 perth cohort characteristics and demographic characteristics of children in each public open space access group none nonchild friendly or child friendly public open space within 800 m 400 m from childs data availability statement the linked aedcbe dataset may be available for research purposes pending appropriate data use approvals from the human research ethics committee data custodians and research team for more information please contact institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the royal childrens hospital human research ethics committee and rmit university human research ethics committee approvals were also obtained from the aedc data custodiansaustralian government department of education skills and employment through the social research centre and the authorised data linkage agency a memorandum of understanding between aifs and dese was also undertaken informed consent statement participant consent was waived due to the following reasons outlined in the national health and medical research council national statement on ethical conduct in human research no suitable alternatives involving fuller disclosure an optout approach is not feasible and obtaining explicit consent is neither practical nor feasible given the scale of the project participants will not be exposed to an increased risk of harm as a result of this study and results will be reported as aggregated data the research is considered lowrisk and limited disclosure is unlikely to affect participants adversely and potential benefits of the research are sufficient to justify any risk of harm associated with not seeking consent this research is well aligned with the global and australian agendas on building healthy liveable and child friendly cities as such appropriate ways to explore associations between neighbourhoodbuilt environments and early childhood outcomes are required to provide an evidence base that supports which neighbourhood characteristics make a difference

neighbourhoodlevel interventions offer a promising opportunity to promote child mental health at a population level however neighbourhood effects are still regarded as a black box and a better understanding of the specific design elements such as public open space is needed to inform actionable policy interventions methods this study leveraged data from a population linked dataset australian early development censusbuilt environment combining information from a national census of childrens developmental outcomes with individualised geospatial data associations between access to within 400 m and 800 m from home and quality of public open space and child mental health outcomes across eight capital cities were estimated using multilevel logistic regression models adjusting for demographic and contextual factors access was defined based on proximity of public open space to childrens home addresses within distance thresholds 400 m 800 m measured along the road network effect modification was tested across maternal education groups results across the eight capital cities inequities in access to child friendly public open spaces were observed across maternal education groups and neighbourhood disadvantage quintiles children with access to any type of public open space within 800 m of home had lower odds of demonstrating difficulties and higher odds of competence children with access to child friendly public open spaces within 800 m of home had the highest likelihood of demonstrating competence conclusion improving access to neighbourhood public open space appears to be a promising strategy for preventing mental health difficulties and promoting competence in early childhood action is needed to redress sociospatial inequities in access to child friendly public open space

introduction demographic transition coupled with rapid social changes poses a serious threat to the aging population in india changing family demography has affected the wellbeing of older adults by depriving them of familial support and changes in values and norms in society 12 on the other hand living as a household head signifies a greater degree of independence than living in a household under someone elses authority 3 however the shift in the status of the aged from dominant to subordinate position occurs quite prominently with the advancing age 4 understanding the potential factors that could have accounted for such changes in household headship status of older adults may help improve policy and services that would support and uphold their role and authority in the family system household headship is seen as a reflection of both incomeearning as well as decisionmaking status in the household 5 6 7 as an index of family status headship signifies the importance of the family member concerning their power to control and allocate the familys economic and social resources a greater degree of economic and symbolic power 8 on the other hand the loss of headship can be a cause of disregard for the aged and is associated in a very fundamental way with other status losses such as retirement and widowhood that mark the transition into the final life stage 9 interestingly the headship status in asian countries is unstable for example independent living is preferred as one phase of the life course while having adequate economic resources 10 and that would give way to the traditional form of coresidential living sons or daughters headship when the older parent becomes frail and chronically ill 11 earlier studies revealed that heading an independent household is a function of age marital status parental status and individual income 12 economic resources including pension receipts are also seen as helping the older parents to maintain their locus of power in the household which could be eroded by becoming a burden to other members in an extended family system 13 another study in thailand found that the extensive rural to urban migration of adult children have not led to the widespread desertion of leftbehind older parents unless frailty and poor health required daily personal assistance 14 nonetheless as couples grow too old and infirm to maintain separate households they either enter the households of their children or a nursing home and other institutions 15 in the case of unmarried older adults they are left to choose among living arrangements that are much complex such as with extended kin nonrelatives or they may live alone 8 family structure and household headship in asian countries including india strong family values are maintained with many people living in extended family households either together or close by for their psychological social and physical needs 16 once settled family headship continues over the family life course unless critical events such as divorce or migration disrupt the family structure despite the strong stability of family headship agerelated events such as the decline in health and death of spouse limit older persons ability to maintain their independence and require adjustments in their living arrangements that will affect their headship roles 17 the family in india is considered as a group of people that includes both the living generations immediately above and below the household head and their predecessors and those who are yet to be born 18 the majority of older people live with their immediate family members and the family continues to be the main provider of care for the aged 19 notably the indian joint family has always been regarded as an ideal group of people that is bounded by the loyalties towards the members living together in one household under the authority of an older person 20 furthermore the heads of most of the families are older people and they are cared for and respected especially those who were medically healthy and performed their daily activities independently 21 when parents and unmarried siblings are working married sons feel that there is no reason for them to delay entering the life stage defining masculine adulthood that of the head of household they do so by setting up their own nuclear family frequently by requiring parents to subdivide the family home 2223 hence the older parents lose their household headship in the indian context despite huge changes in demographic behaviors the family continues to be the major source of psychosocial support for older adults hence there arises the need to understand how transitions in family structures affect the experiences of headship changes among older adults more than a crosssectional view there is a necessity to examine such association over time our study had tried to explore this gap in the literature and used the panel dataset to examine the effect of family structure in elevating the chances of gain or loss of household headship among older adults within a period of seven years data and methods data source the current study used the india human development survey wavei and waveii ihds wavei is a nationally representative and multitopic survey of 41554 households conducted during 200405 across all the states and union territories of india excluding the andaman nicobar islands and lakshadweep 24 ihds waveii conducted during 201112 is also a nationally representative and multitopic survey of 42152 households with geographical coverage similar to wavei 25 both waves of ihds adopted a multistage stratified random sampling approach ihds waveii reinterviewed 83 of the households from wavei further details regarding ihds sampling and data collection procedures can be found elsewhere 2627 during ihds wavei there were 17906 individuals aged 60 years and above whom we refer to as older adults in this study among them 4736 older adults were not alive and 2643 older adults were lost to followup during waveii thus our current study is based on panel data of 10527 older adults additionally there were no records with missing information for all the variables used in our study the second indicator measures whether older adults who were household heads during wavei had lost headship during waveii both these outcome indicators were obtained from every individuals respective headship status during both waves of ihds in the gained headship variable older adults who were not head in wavei and became head in waveii were coded as yes and if they were not head in both waves then they were coded as no similarly in the lost headship variable older adults who were head during wavei but became not head during waveii were coded as yes and those who were head in both waves were coded as no explanatory variables household family structure during wavei is the main explanatory variable of this study the household family structure variable was obtained from the information given on the relationship of each household member with the head of the household based on this information the family structure was categorized into three family typessingle generation nuclear and joint extended family the single generation includes a marriedcohabiting couple or a singleperson household the nuclear family includes marriedcohabiting partners along with their dependent and unmarried children the joint family includes a parent andor partner along with their children and grandchildren the extended family is similar to a joint family structure with the exception that it also includes extended members that is people who are not directly related to the household head by blood extended relatives include brotherinlaw sisterinlaw daughterinlaw soninlaw stepfather stepmother parentinlaw and servants control variables existing studies show several factors other than family structure which affects the transition of household headship among older adults we controlled for the confounding effects of the majority of these variables in our study conditional to their availability in ihds the control variables related to the individual older adults includemarital status level of education age group working status whether received oldage pension whether suffering from chronic diseases we also controlled for relevant demographic socioeconomic and geographic characteristics that arenumber of married adults in household number of unmarried adults in household number of children in household gender of the household head household wealth quintile household below poverty line status the caste of the household scheduled castes other backward classes others the religion of the household place of residence country regions all the above characteristics were measured for the older adults during wavei during wavei ihds collected information on the marital status of each individual from a household the marital status was originally categorized into six categoriesspouse absent married single widowed separateddivorced and no gauna judging by the percentage of individuals in each category we have recoded the original variable into a binary marital status variable individuals who were single widowed separateddivorced spouse absent and no gauna were recoded into the not currently married category otherwise they were included in the currently married category the variable of whether an older adult suffers from any other chronic diseases during wavei were obtained from the information on whether each individual suffered fromcataract tuberculosis high blood pressure cardiovascular diseases diabetes leprosy cancer asthma polio paralysis epilepsy mental illness sexually transmitted diseases and any other chronic disease if an older adult suffered from at least one of the above chronic diseases then they were coded as yes and otherwise they were coded as no the household wealth quintile for wavei was calculated using principal component analysis 28 we generated wealth scores for each household using the available information on household asset ownership livestock ownership building material used in household household water source household sanitation facility and the number of rooms based on the wealth score we categorized the households into five categories such that the households with the lowest 20 percentile score belonged to the poorest category households with the next low 20 percentile score belonged to the poor category and so forth the country regions during wavei were formed by dividing the erstwhile 33 states and union territories of india into six regions the northern region includes chandigarh delhi haryana himachal pradesh erstwhile jammu kashmir punjab uttaranchal and rajasthan the northeastern region includes assam arunachal pradesh manipur meghalaya mizoram nagaland tripura and sikkim the central region consists of madhya pradesh and chhattisgarh the eastern region includes bihar jharkhand odisha and west bengal the western region comprises dadra nagar haveli daman diu goa gujarat and maharashtra the southern region comprises erstwhile andhra pradesh karnataka kerala tamil nadu and pondicherry statistical methods we performed bivariate and multivariate analysis to achieve the study objectives owing to the binary nature of the outcome variable bivariate analysis was done using the chisquare test for association equivalently multivariate analysis was performed by estimating multiple variable logistic regression models bivariate and multivariate analysis was performed in two sets by taking gained headship and lost headship during waveii as the outcome variable respectively odds ratios in the multivariable models show the association between the outcome variables of transition in headship and the independent variables the odds ratio measures the odds of losing headship relative to having an unchanged headship status among the older adults belonging to a particular category of an explanatory variable given the effect of all the other explanatory variables remain constant 29 the odds ratio can take any value above zero with a value between 0 and 1 denoting a negative association and a value more than 1 denoting a positive association additionally we checked for multicollinearity in both the regression models and found the mean value of the variance inflation factor to be less than 19 thus our estimated regression models do not suffer from multicollinearity the use of panel data requires the application of panel weights unfortunately the results given in this study are unweighted as ihds does not provide separate panel weights for analysis all the statistical estimations were done using the stata 13 software 30 results descriptive findings fig 1 depicts that 83 39 and 676 of older adults residing in a single nuclear and joint family structure in wavei respectively had experienced no transition in their family structure from wavei to waveii further 01 and 25 of older adults had moved from a single generation to a nuclear and extended family structure respectively across the two rounds nearly 62 of older adults had experienced a change in family structure from nuclear to extended while 68 of older adults had moved from extended to single generation family structure as shown in fig 2 the percentage of older adults who were residing in a single generation household in wavei increased to nearly 6 in waveii in contrast older adults residing in the nuclear family structure had decreased from 121 in wavei to 67 in waveii about 1 decrement was also seen among the older adults residing in joint or extended family structure from wavei to waveii table 1 shows the characteristics of 17904 and 10527 older adults respectively in the crosssectional and panel datasets during wavei in the panel dataset 77 of older adults resided in a joint or extended family during wavei further 67 of older adults were married 60 had no formal education and 85 were unemployed during wavei additionally 70 of older adults belonged to the age group of 6069 years and only 67 of older adults received an oldage pension 91 of older adults come from a household with a male head 20 belonged to a poor household while 74 of older adults reside in rural india a majority of the older adults belong to the northern and southern regions of india respectively overall we observed that the percentage distribution of older adults by the socioeconomic and demographic characteristics was indeed similar in crosssectional and panel datasets only percentage distribution by marital status age group and place of residence differed by more than 3 points between the two datasets bivariate association from table 2 out of the panel of 10527 older adults 5334 and 5193 persons were not head and head of the household in wavei respectively among 5334 older adults who were not head in wavei 657 older adults have gained headship during waveii further among 5193 older adults who were head in wavei 635 older adults lost their headship during waveii among older adults who resided in a single generation family in wavei 255 had gained and 56 had lost their headship in waveii almost 26 of older adults who reside in the nuclear family structure in wavei had gained their headship during waveii in contrast to 78 of older adults who lost their headship further only 105 of older adults from a joint or extended family structure in wavei were able to gain their headship in waveii gaining headship was common among older adults who were married and had 610 years of schooling education in wavei about 16 of households with no married adults shows gain in headship among older adults almost 141 older adults in the age group 6069 years in wavei had gained the headship in waveii and 249 older adults who were 80 years and above in wavei had lost their headship by waveii around 8 of working older adults and 146 older adults who had a chronic disease in wavei had lost their headship in waveii 272 of female older adults who were head in wavei had lost their headship in waveii approximately 155 of older adults from the northeastern region in wavei had gained their headship while the loss in headship was mostly observed in southern regions multivariate association estimates from two different logit models showing the change in the headship status of older adults in the household are shown in discussion using a panel dataset of the india human development survey the present study found that within seven years 68 of households had transitioned from extended to single generation and nearly 19 of households from nuclear to a single generation the results were consistent with previous studies where it was found that the proportion of oneperson households which in our study comes under single generation households was increasing due to increased urbanization and labor migration 3132 similarly it was also revealed that single generation households had increased from 109 to 17 in almost seven years and nuclear family structure decreased from 121 to 67 which is again an interesting finding when living arrangements of older adults are considered the results were consistent with the findings of the indian demographic and health survey data which revealed that the nuclear family structure among older adults had significantly decreased from 199293 to 201516 33 importantly changes in the family demography plays a major role in the headship transition of older adults studies found that an increased quest for privacy among the young led to a sharp rise in the early marriages and that in turn raised the proportion of the young male household heads 34 in this regard the marital statuses of the children which result in disaggregation of the household contribute to the loss of headship among older parents and the automatic attribution of headship to the senior member of the family cases to be the norm 35 the present analysis also shows that older adults who live in the nuclear family had higher odds of losing their household headship in comparison to older adults who live as single generation ie either alone or with a spouse the results are consistent with previous studies which found that in india oneperson household headship is increasing especially among older women 32 moreover in some cases the adult children become household heads but prefer a separate living arrangement and move away from their older parents determining the proportion of these cases in the indian context is important and its impact on older adults wellbeing is subject to further investigation 3637 the loss of headship in nuclear and jointextended family was high probably because as evidence suggests when the son gets economically dependent or gets married then the probability of loss of headship increases among older adults 9 there is a huge scope to look into the household dynamics ie whether the son is married or not or whether he is financially dependent or not which would in turn affect the headship status of the older adult moreover it was found that grownup children tend to make decisions as they become the main breadwinners in the household and in turn the decisionmaking power of older persons in india has been declining 38 this suggests that in the indian scenario there is a voluntary transfer of headship to the economically active sons the older adults who were currently married had higher odds of gaining household headship in comparison to older adults who were not currently married the relationship can be understood in the context that if in older age the spouse is dead it may have adverse consequences on the surviving older adult widowhood may affect mental health and social participation and result in behavioral issues in the surviving partners 3940 these changes are likely to affect the decisionmaking skills and hence the loss of headship is high among older adults who were widowedseparatednever marrieddivorced however as evidence suggests in most cases the older member of the family is deemed to the formal head and the actual management of the house is run by the adult son 41 moreover how the loss of a spouse affects the value of older adults in the later years of life is the prime area of investigation because if the value deteriorates then it may lead to loss of headship and viceversa previous studies argued that older adults with higher educational status had an increased probability of losing their household headship 33 the present results are however inconsistent and suggest that older adults with higher educational attainment had lower odds of losing headship hence the loss of headship among educated older adults is an area that warrants further investigation besides the age gradient was considered as the most important predictor for loss of headship among older adults as people grew old they are considered a liability by the younger family members and hence had higher chances of losing headship 42 further we observed that older adults who were working were less likely to lose their headship which supported the notion that older adults with better economic status had the greater bargaining power to choose their status in the family 4344 in the present study it was also found that older adults with a pension had higher chances to lose headship the reason would be that the beneficiarys pension would not be sufficient to prove his position in the family with a secured economic status in this context although the person may not be the head but may make household decisions the concept of nominal head and functional head may be an interesting factor for further investigation however the finding is contrary to a study that found that older adults who receive pension had reported better social status independence and better quality of life 45 also previous studies have shown that poor older adults had higher chances of losing power and headship since they are considered as no more capable of contributing to the household economy and becoming a burden on other family members 434647 nonetheless our study found that older adults coming from a household below the poverty line had higher odds of losing their headship furthermore older adults with chronic conditions had higher chances of losing household headship which is consistent with previous studies the reason stated was that older adults with chronic diseases become dependent on their children or other relatives and hence lose their relevance in the family and household headship 948 the movement of older adults from one household to other due to worsening health conditions affects the headship status 9 also the worsening condition would probably affect their decisionmaking skills hence loss of headship may happen at older ages women were more likely to gain headship at older ages as they are more likely to be widowed and hence had higher chances to become head following the departure of their spouse 32 further older adults from urban areas were having higher odds of gaining headship the result was parallel with previous studies where it was argued that adults in their older ages from urban areas were more likely to be the household heads 9 older adults from the southern region of india had higher chances of losing the headship which can be explained by the increasing number of nuclear families in southern states of india 49 however the reason behind is yet to be investigated further and a dearth of literature on the regional variations in the headship status of older populations provides a window for further investigation the study had certain limitations which should be mentioned firstly the data is eight years old therefore one should be cautious while generalizing the results at present however the association may still persist secondly the status of the son is not available in the dataset this could have been one of the important predictor of gain or loss of headship status for older adults as if the son is the sole breadwinner of the family he would have been the head of the household or the main decision maker of the household lastly chronic diseases were selfreported and may add to the response bias moreover future studies examining the association between family structure and transition in headship status can look into the interaction effects of explanatory variables in the observed associations however acknowledging the strengths the study provides a detailed information on an utmost important concept of gain and loss of headship among older adults in india although the data is older ihds was the only publicly available panel dataset that would allow us to examine the headship transition among older adults in india this also indicates the need for a new comprehensive quantitative dataset that covers multiple aspects of family demography in india conclusion it can be concluded that the loss of household headship was significantly associated with the type of family structure the present study reestablishes the importance of individual and household level determinants of headship status such as income health and the fact that privacy and independence in later ages are being increasingly achieved at the cost of weakening the family ties in this regard the emergence of an increase in single generation households along with declining joint families has changed the character of household headship for older individuals however living in a singlegeneration household may preferably be encouraged among older adults than their living in a complex household without headship thus public intervention may support independent living within the older population through housing policies that create additional choices presented to older adults making residential decisions nonetheless the research questions remain such as whether the cultural differences availability of children and objective health indicators have affected the household headship status late in life than the indicators the analysis of which yielded the current conclusions moreover a potential line of inquiry would be to distinguish the determining factors and changes in household headship rate in the people from younger age groups and its effect on the headship status of their older parents studies related to indias aged population from the family perspective are becoming extremely important given the increasing proportion of aged persons in the population composition of the nation this study used a publicly available secondary dataset with no information that could lead to the identification of the respondents the ihds datasets used in our public intervention may support the independent living within the older population through housing policies that create additional choices presented to older adults making residential decisions study can be downloaded from the interuniversity consortium for political and social research data repository eduwebdsdrseries507 ethics statement our study utilized publicly available secondary datasets with no information that could lead to the identification of the respondents therefore prior ethical approval for using these datasets was not necessary further these datasets were collected and owned by a thirdparty and the authors did not have any special privileges for accessing these datasets

despite huge changes in demographic behaviors the family continues to be the major source of psychosocial support for older adults in india the loss of household headship can be a cause of disregard for the aged and is associated in a very fundamental way with other status losses our study used the two rounds of the india human development survey to understand the association of family structure on the gain or loss status of household headship among 10527 older adultsbivariate analysis was done using the chisquare test for association equivalently the multivariate analysis involved estimating multivariable logistic regression models multicollinearity did not affect the estimates from the regression models for examining headship transition we performed two complete sets of analysis by taking gain in headship and loss in headship as the outcome variable respectivelyacross two rounds a major shift in family structure was noticed as 68 of households moved from extended to a single generation results indicate that family structure was significantly associated with gaining and losing headship among older adults headship loss was more common among nuclear or 216 ci 128 365 and extended or 276 ci 164 466 family structures moreover gaining headship was found to be significantly associated with married educated and working older adultssince living in single generation household may preferably be encouraged among older adults than their living in a complex household without headship and value they deserve the

introduction this study was selected in the backdrop of rising number of various forms of child abuse incidents depicting the sufferings of the weaker being whose only fault may be their dependence on others for care and protection however they are mostly treated with torture humiliation deprivation sexual violence and murder the perspective of islam on abuse the injunctions in the holy qurān the illustrations from the sunnah and the teachings and conduct of the pious men should be propagatedhighlighted as an example to be followed by others to find a solution to this menace of child abuse in the religious light many children have been subjected to abuse torture and inhuman treatment since time immemorial and its traces stretch over human history with horrifying details a dig at the history of abuse and violence makes shocking revelations that how this is so much innate in the human nature thriving on the passionsemotions of lust power hunger fear wealth ritual religion pride ignorance apathy etc and the children have been subjected to all kinds of violence and tragedy by whom he was dependent upon or otherwise in the most astonishing way child abuse has been a pervasive phenomenon with variation in the extent of abusive treatment throughout human history ranging from apathy slapping or scolding to genital mutilation used as a tool either to regularize the child or to uphold the social and cultural norms or simply as a passage to vent the simmering emotions of excitement or revulsion with repercussions beyond imagination upon the defenseless souls who deserving care protection and kindness child abuse is a grave problem with myriad consequences it is the violation of the very rights of the child on the part of those upon whom he depends either by ignoring the rights or behaving with the child in such a way that affects him negatively it has repercussions to the psyche of the child damages his emotional wellbeing to his health undermining his growth and development moreover it entails threat to the very survival and existence of the child child is defined as progeny offspring of parentage unborn or recently born human being at common law one who has not attained the age of fourteen years though the meaning now varies in different statutes as per blakes law dictionary abuse is defined as everything which is contrary to good order established by usage departure from reasonable use immoderate or improper use physical or mental maltreatment misuse deception to wrong in speech reproach coarsely disparage revile or malign hence child abuse stands for any form of cruelty to childs physical oral or mental wellbeing also used to describe form of sexual attack which may or may not amount to rape world health organization founded in 1948 is united nations agency which aims to keep the world safe and serve the vulnerable defines child abuse maltreatment as child maltreatment is the abuse and neglect that occurs to children under 18 years of age it includes all types of physical andor emotional illtreatment sexual abuse neglect negligence and commercial or other exploitation which results in actual or potential harm to the childs health survival development or dignity in the context of a relationship of responsibility trust or power broadly defined child abuse or maltreatment constitutes all forms of physical andor emotional illtreatment sexual abuse neglect or negligent treatment or commercial or other exploitation resulting in actual or potential harm to the childs health survival development or dignity in the context of a relationship of responsibility trust or power a look at the history terrifies the conscience with a sad apprehension that child abuse happened to be prevalent in human history irrespective of region culture sex or era children have been subjected to all kinds of atrocities either in the name of culture rituals victimization habit or norms with either wide acceptance or passive disdain lloyd demause in his speech the history of child abuse while calling child abuse humanitys most powerful and successful ritual bluntly puts it as …my conclusion from a lifetime of psychohistorical study of childhood and society is that the history of humanity is founded upon the abuse of children child abuse is such a subject which cannot be studied in isolation rather at times even one kind of child abuse possess traces of multiple types of abuse exempli gratia sexual abuse often involves abduction mutilation physical abuse verbal abuse etc and in extreme case involves killing or death of the victim a few cases of children survived fear victimization exploitation and deprivation while in todays world though the plight of children has not much changed but the only difference is that at least mistreatment abuse and deprivation has been recognized as a problem with concerted efforts to minimize it or atleast its effects on national and international level child abuse though practiced widely is highly despicable phenomenon to any sane mind that all the provinces of pakistan have made legislations to recognize and curb this heinous practice as may be suitable to them to address to the plight of the children the alarming part is that mostly people are unaware about the gravity of their actions against children besides generally masses are unaware about the laws and punishments awareness about various child protection and rehabilitation agencies working at national and international level also the rewards and repercussions of this heinous crime are not being disseminated properly repeated negative actions become habits and make one insensitive to the point that one is unable to discern right from wrong corporal punishments child sexual abuse sense of fear exploitation etc is all what has surfaced thanks to electronic and social media in the very recent times raising the questions regarding various social issues including child abuse the overall picture of child safety and protection has been grim in pakistan and child abuse has become a norm of the day pakistan is a densely populated country with approximately onehalf of its population being children and adolescents and it is essential to safeguard these children and adolescents to promote their welfare and protect them from harm a dig at the cases gives one goosebumps that how children have suffered for no fault of their own and became a victim of anger aggression power terrorism ignorance pride and lust of others for example zainab murder case aps tragedy javed iqbal and murder of 100 plus children malala attack kasur abuse scandal little angel shot kashmore gang rape victims of teachers furry victims of domestic violence etc human rights commission of pakistan in its report published as state of human rights in 2021 based on the data provided by child protection organizations on average more than ten children are subjected to sexual abuse every day in pakistan data collected from all four provinces of pakistan in the first six months of 2021 revealed that a total of 1896 cases of child abuse were reported across pakistan and out of these 1084 cases were of sexual abuse against children 523 were cases of abduction and 238 cases of missing children statistics from the province show that 60 percent of the total cases were reported from punjab children between the ages of six and 15 yearsboth boys and girlsremained the most vulnerable to abuse and violence an analysis of cruel numbers 2021 compiled by sahil is as under in the year 2021 the data on child abuse cases shows that a total number of 3852 cases have been reported in 88 national and regional newspapers these cases were reported from all four provinces including islamabad capital territory azad jammu and kashmir and gilgit baltistan the data indicates that a total of 3852 cases include reported cases of child sexual abuse cases of abduction cases of missing children etc the data shows that more than 10 children have been abused per day during the year 2021 the cases of child abuse have increased by more than 30 as compared to the year 2020 the gender divide shows that out of the total reported cases of child abuse 54 of victims were girls and 46 were boys the reported age shows that children are most vulnerable to abuse in the age group of 615 years in which more boys than girl victims were reported moreover children as young as 05 years are also sexually abused the abusers category of cruel numbers 2021 indicates that mostly acquaintances involved in child sexual abuse along with service providers family members strangers and women abettors who have increased from 29 cases in 2020 to 86 cases in 2021 the geographical distribution of the data shows that out of the total 3852 reported cases punjab has the maximum number of reported cases out of the total 3852 reported cases 2211 cases are reported from rural areas and 1641 cases are reported from urban areas among the total reported cases over 80 were registered with the police the cases of only csa were 2275 with both genders equally victimized a total number of 92 cases reported murder after sexual abuse a total number of 1303 cases were reported of abduction out of which 233 cases were reported of sexual abuse after the abduction a total number of 438 cases of missing children were reported the year 2022 presents another bleak picture with an alarming rise in child abuse cases in its first six months ie from january to june the statistical representation from sahil cruel numbers 2022 highlights that during 2022 january to june 2211 children were abused…cruel number data reveals that 1207 girls and 1004 boys are victims of exploitation this data brings the numbers of abused children more than 12 per day this year reported cases under major categories are abduction 803 rape 243 sodomy 298 gangrape 41 and gang sodomy 87 as many as 17 boys and 13 girls have been murdered after committing sexual abuse there are more horrible incidents in which 2 boys and a girl were murdered after gang sodomy and rape and 212 children were found missing the statistics show that out of total 2211 there are 1050 cases where the abusers have acquaintance with victims or victims family 409 cases are reported in which strangers are involved in abusing victim blaming especially in the cases of females has been prevalent in pakistan female gender is but an entity for criticism it is wondering that how could a minor girl carries herself inappropriately to entice her perpetrators to take it as a treat to entertain themselves rather the exposition is different if we look back to the case of 3 years old minor from kashmore in sindh pakistan exposing herself to tell the media what was done to her by the uncle voices of blaming are often being heard from the intelligentsia and custodians of the rights of all the segments of the society and an array of explanation and interpretation notes by the aides of the head of the nation and others its explanation can be sought from patriarchal culture from which we hail or because of the incapacity of the state to handle this problem and the simple implication of the victim in the crime against herhim serves the end of doing away with the problem child abuse is a taboo topic and at times even not considered to be a problem in pakistan as there is a just a narrow difference between abuse and admonition and it is a justified phenomenon in the rearing of children as far as child sexual abuse is concerned usually people shy away from this topic and it remains limited to mere breaking news slogans placards and lightening of candles and then a forgotten incident without delving into the nature of abuse and its prevention here the contention has been upheld that usually children suffer at the hands of others and human behaviors responses apathy is the root cause to this menace and religious knowledge and teachings are being eulogized as something sacred instead of practical most of the works relate the rights of children originating from the qurān and hadith but do not focus on child abuse and its solution in the light of religion since no study has explicitly focused on the topic of child abuse as a problem from the indigenous point of view combined with the role of the religion therefore this task was taken up by the authors to explore the public opinion with reference to this phenomenon of child abuse and role of religion methodology this research intends to explore the attitudes and opinions of the people regarding child abuse while using a quantitative approach a survey was conducted to collect data from diverse group of people for this purpose a questionnaire was developed to solicit the responses from the sample drawn from the targeted population population and sampling people of lahore division comprising of district lahore nankana sahab kasur and sheikhupura have been selected to get the opinion regarding child abuse sample size has been aimed at 200 participants for this research research instrument to capture the ethereal attributes of human behavior and performance it is necessary to transform an individuals subjectivity into an objective reality to achieve this a questionnaire has been designed with likerts scale for gauging the opinion and attitudes of the people the questionnaire consists of twenty questions comprising of 5point scale ranging from strongly agree to strongly disagree the questionnaire was designed with general and targeted questions to assess verify some notions and extract opinions on certain questions and issues to arrive at a definitive point the questionnaire depicts division of questions on three planes viz individual social and institutional data collection after formulation of questionnaire it was distributed among the targeted population ie people of lahore division including kasur nankana sheikhupura and for this purpose volunteers were assigned the task of the distribution of questionnaire among people of the four regions with wider access so that opinions may be solicited from wider range of the same area the data was collected in ten days period extending between 04112022 to 14112022 considering the fact of targeted sample size of 200 the distributed questionnaires exceeded the original limit in view of no response lost or not returned and finally the collection was brought to the required level the population distribution of 200 in the lahore division comprising of the following districts is as under lahore 70 sheikhupura 50 kasur 50 nankana 30 41 data analysis collection of data proved to be an uphill task as the questionnaire forms were retuned either blank or halffilled and where the questionnaire was filled the personal information of the respondent was scant therefore extra questionnaires were again distributed to acquire the requisite number of responses to process after gathering requisite qualitative information it was refined and quantified the personal information of the respondents was collected and categorized into different heads besides this all the responses falling under the same category were combined and converted into percentage form and table charts respondents demographic information target population was 200 of lahore division which is demographically defined by the following graphical representation gender division of the respondents the gender distribution as per analysis of the data shows that both males and females have put forwarded their opinions with males as higher no of respondents and the age of all the respondents was above 18 years as gauged from the personal information the gender distribution is as under figure 2 gender distribution of the respondents as marital status is concerned 135 respondents were married and 55 respondents were unmarried while 10 of them did not mention anything figure 4 education of the respondents occupation of the respondents the way respondents depicted diverse educational background similarly their profession description was myriad they were students doctors government servants lawyers teachers laborer electrician pharmacist businessman tailor mechanic shopkeeper factory worker private job holder blacksmith housewife and unemployed results and findings out of 200 respondents over threefourth agree and totally agree to the statement that child abuse is a major problem of our society today while 13 replied that they dont consider that child abuse is the biggest problem and 9 were undecided to comment a vast majority of the respondents showed their personal concern over the alarming increase in the child abuse cases while 65 were undecided to opine and 25 didnt show concern and 1 respondent left the question unanswered concern over the alarming increase in the number of child abuse cases children should be guided about their safety and protection 68 table 5 children can only be trained by punishments a whopping 905 of the population agreed that there are injunctions in islam regarding treatment of children and 55 remained undecided 25 disagree totally disagree and a very few left the space unanswered table 6 injunction about children in islam there was a limited number of the respondents who knew about organizations working for the rescue and rehabilitation of children over onethird of the respondents replied positive while almost a similar proportion remained undecided to answer whether they know of it or not over onefourth claimed that they dont have any information about such bodies while a very few left the space blank injunctions about children in islam table 7 knowledge about the address and contact number of at least one organization working for the rescue and rehabilitation of children over twothird of the respondents agree totally agree that islamic injunctions are not being highlighted in our society while 275 of the population disagree totally disagree to the statement and 85 remained silent to answer and 1 respondent gave no response table 8 islamic injunctions regarding children are not being propagated in our society a vast majority of the respondents agree and strongly agree that abusive behavior with children affects their personality and 45 remained silentundecided and 55 disagree and totally disagree with it one percent did not answer the question most of the respondents believed that safety of the child is the responsibility of all the major institutions including family society and state 4 remained undecided while 6 disagree totally disagree with the statement over onehalf of the respondent replied that their mosque shows concern over the rising number of child abuse incidents while some were undecided and 40 disagree totally disagree that mosque shows concern over the plight of children table 12 mosque of my area shows concern about the rising child abuse incidents in its sermons over onethird of the respondents agree totally agree that the mosque of their area preaches the good conduct to the children 16 remained undecided 18 disagree or totally disagree to the statement and only one respondent did not answer mosque of my area shows concern about the rising child abuse incidents in its sermons table 13 mosque of my area preaches good treatment of children less than one half of the respondents agree totally agree that the mosque of their area propagates good treatment of children with reference to the verses of the holy qurān or hadith tradition of the holy prophet daily a reasonable proportion among them remained undecided on the question and 285 disagree totally disagree that their mosque gives reference from qurān and sunnah daily mosque of my area stresses the importance of good treatment of children by referring to the verses of the holy qurān and ḥadīth daily around onehalf of the respondents agree totally agree that mosque of their area preaches about the good treatment of children by narrating traditions from the life of the holy prophet 28 disagree totally disagree and an equal number of respondents 23 remained undecided table 16 mosque of my area explains the importance of good treatment of children by narrating traditions from the life of the holy prophet onethird of the respondents agree totally agree that their mosques stress upon the good values and morals by narrating examples from the lives of mystics of islam some of them disagree totally disagree and 19 were undecided only one respondent did not answer mosque of my area explains the importance of good treatment of children by narrating traditions from the life of the holy prophet table 17 mosque of my area guides about high moral values by giving examples from the lives of sufis and saints most of the respondents agree totally agree that mosque of their area preaches that islam guides to improve human conduct 105 disagree totally disagree while 55 remained undecided about the opinion over 800 of the respondents agreed totally agreed that media can play its role to guide the children about their safety and training while 105 disagreed totally disagreed and 4 remained undecided on the statement table 20 media can be utilized to disseminate information regarding safety and training of children the analysis of the above data suggests that child abuse is the biggest problem of this time people are sensitive about this issue and have shown personal concern over the alarming increase in child abuse cases child sexual abuse has been established as the worst kind of abuse and the society in general acknowledges this fact in the face of the wrongs that children suffer it is need of the hour to guide them about their safety security and sanctity and majority has opined in the favour of imparting selfprotection education to the children there can be as many ways to train children as may be their number each personality is different and punishment is highly derisive and not a solution to the problem of training the kids the majority of the population disagreed that punishment is necessary to train children media can be utilized to disseminate information regarding safety and training of children population agreed on earlier that there are injunctions and teachings regarding treatment and rearing of the children islam there also a significant number of respondents showed concern that the same are not being propagated for the benefit of children and others child abuse is the grim reality of our society and affects the personality of the sufferer badly or negatively which means that child abuse has consequences the majority of the population was of the opinion that child abuse has repercussions for the child beyond explanation the problem of child abuse cannot be tackled in isolation and all the stake holders should participate for the safety rescue and rehabilitation of this weak and dependent population of society most of the respondents agreed that children are the responsibility of all and a joint endeavor imbibing the efforts of family society and state are needed to improve the lot of the kids mosque is an important institution in a muslim society and performs various religious and social functions and it is the prime source of dissemination of religious learning and training most of the population agreed that mosque is an important institution of society a just slight majority agreed that mosque holds children important and shows concern over their plight while a significant number of respondent replied that mosque doesnt show concern over children to arrive at a solution for the problem of child abuse it needs a multidisciplinary approach imbibing education health law religion state media and social service sector child abuse in all its forms and manifestations has become an undeniable reality of todays world the primitive people blinded by their hopes and fears committed crimes against children but in todays civilized world the increasing cruelty and intolerance towards children is incomprehensible being living in an islamic country bounded by islamic principles and surrounded by established cultures of respect harmony and compassion the inhuman treatment of the weaker and dependent segment of society is indigestible it is need of the hour that all the stake holders take the responsibility to fix the problem on war footings the nature of child abuse of all kinds has not yet been determined in pakistan therefore we are short of viable solution it may prove to be an uphill task to determine the nature of child abuse as either way it is a complex problem where the victim may be the one that is child but the components which take part in his exploitation and misery may be myriad child abuse arising in the family circle is usually overlooked and not reported therefore it cannot be determined for sure that what are the reasons that lie behind abuse and cruelty to children in the family domain that whether it is the result of socioeconomic status or the parents and caregivers were themselves the victim of violence in their own childhood and this is like letting loose of ones own hidden emotions and disdain for the weak and defenseless moreover there is lack of mantle in state institutions to implement the laws in their letter and spirit and bring the culprits of heinous crimes against children to book the children are being subjected to torture in educational institutions and religious seminaries which is usually termed as the prerogative of matrons and essential for the training of the child and other heinous crimes are also being committed with impunity in the face of less developed and less accessible social service institutions with lack of determination of the nature of child abuse and weak criminal justice system an individual and collective effort should be emphasized conclusion and suggestions to conclude it can be mentioned that rising child abuse incidents have instilled a sense of fear and shame at the same time the issue of child abuse has not yet been sensitized in pakistan to such an extent where it can be referred to concern of all and the occasional hue and cry has not proved a deterrence to ward of this menace usually people shy away from this topic altogether and abuse is often upheld as a norm of child rearing patterns the dissemination of religious moral values can give a ray of hope to the distressed souls as muslims eye on reward not only in this world but in the hereafter as well but the stark reality is that contrary to religious declaration problem of child abuse is more colored by cultural tinge and personal whims and limitations therefore not strictly taken as a problem at all human behaviors are personal and individual usually regulated by culture and religion pakistan is an islamic republic with diversity in culture and cultural traditions but bounded by religious thread though this very thread may be tinged with variation in religious interpretations but in no way it compromises the basic precepts of islam the abuse of children in all its manifestations arising either out of cultural norms or human behaviors can be tackled by the guidelines of religion originating in the qurān sunnah and mystic guidance of saints and sufis child abuse is on the rise in pakistan and the major reason that can be attributed to the unawareness of the people about religious teachings and guidelines regarding the treatment and rearing of the children besides this there is an apprehension that they dont have knowledge and access to social welfare institutions working for the counselling rescue and rehabilitation of children one important factor may be that they are not making a conscious effort to find any pertinent solution the major problem in pakistan is that the nature of child abuse is still undetermined main reasons for child abuse and detrimental effect of abuse need to be further explored by abuse we mean all the major kinds of abuse including physical sexual verbal deprivation etc if the nature gets determined only then a solution can be reached at this aim of determination of nature of child abuse in pakistan falls in the domain of medical and psychology psychiatry profession with the help of social and state institutions however 1 to tackle the problem of child abuse wisely it is prerequisite to make the criminal justice system strong and vigilant for the implementation of rules and laws which aim at the protection welfare and benefit of the children 2 besides this a comprehensive survey must be conducted about the culprits of child abuse of various kinds especially that of child sexual abuse pornography torture etcto know that what made them to commit a such a heinous crime against the innocent beings to look for the solution 3 thirdly medical practitioners and pediatricians should be trained in such a way that if they are treating a case of suspected abuse then they should also take a note of cause of that injury disease and malnutrition etc the data thus complied would be helpful later for policy formulation for the benefit of the children 4 educationists scholars and religious seminaries should be watchful of the conditions of the children and if they ever suspect abuse should make effort to alleviate that by providing counselling to the child or by taking up matter with parents and caregivers and social welfare institutions but in a well thought out way 5 one last and important thing which comes in the purview of all and which is practicable as well is the dissemination and practice of religious injunctions regarding rearing of children and treatment of children 6 media in all its various forms be it electronic print or social media must be utilized for the cause of children it can give space to the content relating to programmes centered on children with special reference to their training scholars intellectual philanthropist parents doctors civil societies all can put their share to bring glad tidings in the lot of poor children it is general perception that now adays we only see what is being portrayed by media and it mostly thrives on political discourse with a limited space to social issues without follow up in todays world media can play a much wider role it can uphold the cause of the safety of children better than anyone else through airing programmes on personal wellbeing and concept of dignity and respect for others along with psychological counselling of children by expert doctors philanthropists intellectual and teachers it can also train the minds of the children to make them involve in positive activities with individual and group designed tasks and strategies to make them grow as a conscious member of society it can be utilized in building up a safe and secure world for our children but in a well thought out way

child abuse is on the rise in pakistan and the major reason can be attributed to the unawareness of the people about religious teachings and guidelines regarding the treatment and rearing of the children moreover there is an apprehension that they do not have knowledge and access to social welfare institutions working for the counselling rescue and rehabilitation of children one important factor may be that they are not considering the severity of the act and its implications for a childs life nor do they wish to address it considering its severity a survey was conducted to seek answers to these questions and a scale was designed to get the responses lahore division including lahore sheikhupura kasur and nankana sahab was identified as population and 200 responses were collected and analyzed both qualitatively and quantitatively which reflects that generally people are aware of the rising menace of child victimization and they take child sexual abuse as the worst form of all abuses majority of the respondents stated that there are injunctions in islam regarding children and equally the similar proportion also admitted that those injunctions are not being propagated children are not a priority by many as gauged from the responses mostly of the respondents agreed that there are injunctions in islam regarding children and mosque can play its role to bring about a change in the treatment of children by disseminating religious teachings research instrument was designed on personal and social level therefore it can be resolved through concerted efforts of individuals and institutions

introduction climate change affects the health and wellbeing 1 of women and men differently this is because women children and other marginalised groups face greater societal risks and inequalities prior to during and following natural hazards this article will use a postconstructivist theoretical lens of social gender roles and intersectionality to analyse vulnerability structural violence and wellbeing loss in the context of climatic changes to further our understanding of noneconomic losses and damages the literature indicates that depression anxiety posttraumatic stress and death by suicide in the context of natural hazards are more often reported among women and youth than middleaged men understanding the root causes of such wellbeing loss can help illustrate the ways in which women and children are made more vulnerable to climatic stress the existing literature on climateinduced mental health impacts is still relatively scarce but includes the study of solastalgia or distress as peoples environment changes ecoanxiety ecodepression and ecoanger or ecological grief and despair furthermore lived experiences from female and youth represent a research gap as studies continue to be narrated around men however a small group of feminist scholars have prioritised the voices of women and girls in their research the loss and damage2 term was born out of a unfccc research policy discourse where article 8 of the paris agreement explicitly highlighted the urgent need to address noneconomic losses nels or nelds which often disproportionately impacts vulnerable groups empirical nel cases from marginalised populations illustrate the increased severity of climatic impacts and limits to adaption in this article we use nel to conceptualise nonfinancial wellbeing losses that money cannot buy back this will further the body of work already describing peoples experiences of loss nel s refer to the climaterelated losses that cannot be traded easily in the market are inclusive of both material and nonmaterial losses and experienced by those most affected by climate change nels cannot be easily monetised such as in the case of loss of culture health and life knowledge or displacement and mobilityrelated losses empirical nel accounts are important as scholars have raised concerns regarding the extensive nel focus on theory and conceptualisation given its contested normative technical and political issues the lack of representation related to gendered wellbeing losses is of particular concern societal and gendered power and control systems channel through these wellbeing experiences and entrench vulnerability or support peoples decisions and desires the literature suggests that climatic changes particularly impact womens and childrens wellbeing negatively however empirical case evidence illustrating experiences of noneconomic wellbeing losses among vulnerable countries societies and populations is scarce and to our knowledge even fewer incorporate experiences of genderbased violence this article therefore applies a theoretical lens of the gender system intersectionality and power and control to analyse empirical narratives surrounding how natural hazards and impacts of violence interrelate with womens and childrens mental health and wellbeing loss or healing3 processes in three case study countries namely bangladesh fiji and vanuatu a theoretical approach to understand climateand gbvinduced wellbeing loss climateinduced wellbeing loss and its link to nel has already been investigated in the context of people on the move or those left behind trapped and immobile both in relation to longer migration and shorter evacuation movements people migrating away from climatic stress may for example settle down in informal settlements life and work in urban slums often overcrowded with poor access to clean water sanitation or health services place people at risk of developing health issues the challenging living environment may result in mental and physical health risks such as depression anxiety trauma and exposure to violent or abusive behaviours over the past decade climatic impacts are reported to become more frequent and intense which primarily influence the health and wellbeing of those already vulnerable specific geographies disasters and health impacts are however overrepresented and few studies investigate the connections between climatic changes and mental health more direct health impacts such as respiratory diseases injuries and death in the context of extreme weather events such as heat waves may be easier to associate to changes in climate but indirect health effects and particularly mental health and wellbeing loss must be understood as deeply embedded in ecological changes societal responses human behaviours and preexisting health risks such as food and water insecurity and inequality displacement and mobility or access to health services this is because wellbeing loss tends to occur as part of longerterm and causal sociocultural patterns we therefore place this climateviolencehealth nexus study within a systems analysis that investigates these correlations as a network of factors whereof some are immediately tied to the environment while others are seemingly nonenvironmental or social political legal financial and psychological factors our systems narrative analysis will pay attention to the wider societal and humanmade relations that increase the risk of climateand violenceinduced noneconomic wellbeing loss we refer to the narrated experiences of wellbeing loss as climateand violenceinduced to avoid any potential misrepresentation that climate change causes violence this study rather understands natural hazards as additional contexts of stress that may worsen increase and prolong the perpetration of violence and control this article understands gender as a socially constructed system of power and control that regulates peoples roles behaviours decisions and opportunities based on the idea of a female and male division and hierarchy it influences all human beings but due to the established power relations some individuals will find themselves systematically marginalised it is the very foundation of all patriarchal societies and womens and childrens marginalisation and increased vulnerability to violence must be understood as inherently reproduced within its structure we combine this theoretical framework of an oppressive gender system with an intersectionality lens that furthers our understanding of the way that social roles and representations intersects and locks people into positions where they are at the receiving end of discrimination marginalisation and violence we understand the perpetration of violence as acts beyond physical violence and assault by incorporating a framework of coercive control where longer patterns of coercive and controlling behaviour by an individual perpetrator or a collective group or system must be understood as acts of violence we choose this framework to position violence beyond foucaults idea of acts of violence that forces destroys or closes the door on all possibilities as foucault argued that the opposite behaviour to violence can only be passivity instead we acknowledge that acts of violence can be passive such as through neglect collusion and complicity which are all key components in understanding ccb as strategically targeted patterns of violence and control women children and other marginalised groups are therefore more likely to end up as victimsurvivors of violence due to its incorporation in a system of power and control children are often targeted as part of the violent act aimed to harm women as mothers in their maternal roles ccb therefore enables a theoretical lens that acknowledges children girls and boys as exposed to gbv the use threat and harm of children serve as a weapon from a position of male privilege to further control mothers and children 4 the unfccc is one climate policy body among others that aims to understand how mental health through climateinduced noneconomic losses can lock vulnerable populations in positions of continuous wellbeing erosion 5 the literature around nel has rapidly increased in the context of wider marginalised populations or geographies such as the small island developing states who have become a leading voice within the noneconomic loss and damage discourse however the representation and voices from marginalised societal groups such as women and children as well as the interrelation between violence against women and children and wellbeing loss are still lacking in the nel literature the nel discourse also questions the normalisation of experiencing climateinduced losses since it may work against mitigation and adaptation efforts we argue that by coupling climateinduced loss with the continuous experience of structural violence and marginalisation we will extend our understanding of how societies can better live in harmony despite climatic changes and natural resource constrains this article also aims to match wellbeing loss with a more inclusive and intersectional human face voice and storyline to work against the generalisation of experienced loss methods and material this narrative analysis examines the lived experiences and storylines related to wellbeing loss and healing in the context of climatic changes and vawc rather than analysing the experiences thematically we approach the lived experiences and local perceptions contextually in our three case study locations bangladesh fiji and vanuatu 6 the empirical and qualitative storytelling sessions were carried out by the authors between 2010 and 2018 and included ethnography and unstructured individual and collective research sessions while a secondary literature narrative review was conducted by the lead author in 2022 the literature narrative review complemented the empirical firsthand descriptions of genderbased and sexual violence in fiji as the field work here involved fewer research participants 4 many domestic abuse legislations these days also recognise children as victims in their own by seeing hearing or experiencing the effects of abuse 5 health and wellbeing are key areas of interest within most climate and sustainability policy frameworks for example the millennium development goals have gone from tracking child mortality and maternal health to good health and wellbeing meanwhile the sendai framework for disaster risk reduction and resilience aims to reduce losses in lives livelihoods and health article 81 in the paris agreement recognize the importance of adverting minimizing and addressing loss and damage associated with the adverse effects of climate change including extreme weather events slow onset events and the role of sustainable development in reducing the risk of loss and damage 6 for other case study narrative articles structured in a similar way see for example mcmichael et al and ayebkarlsson et al in bangladesh the analysis focused on three coastal study sites facing cyclones floods and erosion as well as the informal settlement of dhaka the urban settlement bhola slum hosts settlers from bhola island who first migrated after the devastating 1970 bhola cyclone and thereafter due to riverbank erosion the lived experiences explored opportunities and constraints for women and girls as perceived by both women and men in the context of environmental stress the interviews conducted between 2014 and 2016 in bengali and audio recorded were later transcribed and translated into english further field observations and participatory observations were noted down and visual contexts were recorded through photographs and videos the participants were recruited through snowball sampling while ensuring that the overall informant balance was representative of the study site in terms of gender age socioeconomic and livelihood backgrounds religion and the geographical climate vulnerability of the households in fiji drawing on to the cultural practice of talanoa dialogues semistructured interviews and focus group discussions were conducted in 2010 random sampling combined with snowball technique was used to draw informants from different climate change drr and humanitarian response stakeholder groups the interviews were conducted in english recorded and manually transcribed photographs and notes were taken as complimentary field observations covering the study area nadi river and township to capture historic flood impacts evacuation sites and existing coping mechanisms in fiji storylines emerged around experiences and perceptions of vawc in the aftermath of cyclones and floods next to the empirical data a secondary data narrative review and scoping search were conducted by the lead author in june and july of 2022 web of science google scholar search and news were searched for books peerreviewed journal articles media articles research projects and grey literature and reports investigating flood and cyclonerelated gbsv in fiji since 2000 the reference lists in the selected publications were also reviewed to identify further relevant material a combined narrative analysis of the primary and secondary storylines7 was carried out in the case of fiji all secondary data narratives are referenced back to their openly available sources most of the interviewed participants were living in our empirical study site nadi the 2018 vanuatu study involved ten focus groups associated with un womens markets for change programme the threemonthlong field work in 2018 was undertaken with women working at various marketplaces around efate and explored womens responses including the role of traditional developmentoriented marketplaces in building hope and resilience most women had livelihoods tied to the marketplaces on efate island in vanuatu some participants were from outer islands but sold at marketplaces on efate or were vendors who sold at a central marketplace in espiritu santo a few participants were executive members of the locally run silae vanua market vendor association the research sessions were conducted in open communal areas and were digitally recorded and later transcribed and translated into english by a female local nivanuatu researcher trusted by the participants the sessions were largely unstructured and flexible to allow participant narratives to guide the research a checklist of key themes was used across the group sessions the authors conducted the field work and the narrative analysis using nvivo thematic narrative and discourse analysis the case study countries differ socially culturally and contextually but the storytelling methodology and research focus bring the studies together storytelling methods build on qualitative and unstructured narrative interviewing techniques this methodological approach of using personal life stories is well established within many other research areas but new within climate change research the unstructured openended questions allow space for the participants to fully communicate their perceptions values and life experiences in a way that the empirical insights guide the narratives the researchers understandings viewpoints and biases are therefore reduced while social and cultural values can be registered in between sentences or throughout the storylines the approach has been widely celebrated for its empowering abilities within research involving vulnerable groups as it let marginalised people speak their truth in their own words allowing their voices to be heard the method effectively gathers rich data on sensitive topics values and behaviours where direct questions would be inappropriate offensive or give limited insights mental health research often uses surveys or health assessments aiming to quantify and diagnose socalled disorders these research designs are not necessarily effective in capturing longerterm nonlinear and complex casual wellbeing losses after katrina for example researchers found that many women first reported wellbeing impacts such as depression anxiety or posttraumatic stress years after the hurricane this article will pay attention to how the storylines describe disproportionate impacts upon women and childrens mental wellbeing in the context of climatic changes and vawc the storytelling approach helps capture wellbeing loss that is difficult to identify register and quantify similar research designs can in the future more comprehensively inform global policy around noneconomic losses and damages and beyond the case of bangladesh gendered mobility and wellbeing erosion bangladeshs geographical position in the worlds largest delta supports its dense population while also exposing people to environmental risks one of the oldest adaptation strategies around these risks is to move away through sudden evacuation or longerterm temporary seasonal and permanent ruralurban migration however harsh living conditions in the informal settlements often compromise migrants mental health women and children also tend to face social risks such as vawc that do not impact adult men in the same way gendered roles entrapping spaces and intergenerational cycles of violence many women and girls experienced a shift in their gender roles with the move and livelihood change this was described as a social devaluation that came with transitioning from household labour to working outside the house some women felt that the move provided exciting new opportunities while others expressed a loss of identity social value and honour the empirical narratives explained that women tending to outside work were perceived as having stepped away from gods righteous path which could result in punishment extract 1 8 why are there so many disasters because we must have left his allahs path women are working outside the house and going here and there this is not good we have to return to his path otherwise we will have to face the consequences the cyclone shelter will not be able to save us then i can feel that the weather is changing i think it is happening because we forgot about allah it is the punishment of allah … the cyclone strikes are holy creations the same way god created man he created cyclones therefore god will decide how they will affect you those who have done him right and who have followed in his footsteps will be put in safety some women felt that this shift in labour activities and workplace made them less honourable and healthy one mother for example associated her daughters health issues with her incomeearning activities as a housemaid extract 2 i do not know what disease my daughter has not even the doctor was able to understand what kind of sickness it is she has fevers but it does not show all the time we got sick from doing household work in other peoples houses that is how we got the disease other migrant women turned to work opportunities in the garment industry many slums with large influx of female new settlers therefore form around these factories the poor work conditions received international attention with the 2012 fire and the 2013 rana plaza collapse studies also indicate a correlation between climateinduced female migrant factory work and vawc and that it may lead to depression the research sessions captured how men would take advantage over girls upon their arrival extract 3 9 if a girl moves to dhaka for work she should keep in mind that she has to send money to her parents and that she must wait to marry until her parents want her to do so if she forgets this and gets into a relationship with a man marries him and starts a new family she may suffer in the long run girls often meet men in the 9 see also text extract 4 in supplementary material 8 this article uses a text extract referencing system for analytical transparency of extract 1 extract 2 extract 3 and so on as the word count in this article is limited we were unable to incorporate all the text extracts that serve as basis for our analytical conclusions in the result section we have instead included some of the text extracts in the supplementary material to make it clear what analytical section each text extract in the supplementary material relates to we have numbered them in chronological older and placed a footnote every time an excluded a quote had to be moved to the supplementary material garment factories and start a relationship but the husband may leave her even after she has had his child this is the punishment for marring someone without knowing enough about him the first six months or so the husband may behave well but then what generally happens is that he changes it is the girl then who has to suffer in this situation she can no longer go back home to her parents she will have to work to provide and care for his child she will have to work alone to support herself and her child perhaps she keeps her child somewhere under a tree while she works and when the child cries she comes running to calm her down that is what her life has become miserable … a man can surely get married again even a girl if she is a dreamer she could get married to another man too though it is the child who suffers the most in this kind of situation a mother can remarry with the child or she can leave the child behind … the mother got another husband the father got another wife but what is there for the child what did she get out of all this shame and hatred this is why the child suffers the most few studies link climateinduced urban displacement in dhaka and khulna to compromised wellbeing the longerterm complex pathways leading to reduced life satisfaction are difficult to capture young unmarried women face additional societal risks through shame punishment and stigmatisation that can result in serious wellbeing implications social stigma was described in the sessions as passed down intergenerationally to the children marrying the wrong man could end up costing a woman a lifetime of sadness that only god had the power to erase extract 5 if there was any chance to live a better life where my children had the opportunity to work then i would go back to the village on bhola island however i was left by my husband and then i got sick i do not have any hope left for my future … life was good until my husband got remarried … it is unbearable to utter the words of my miserable story to you i never want to speak of them my husband married three other women besides me you cannot do anything to relieve my sadness or misery only allah can help me child marriage came up as a common coping mechanism to income loss and food insecurity it must be understood as a form of structural violence that poses serious mental health implications upon girls a woman perceived her kidney failure as associated with giving birth at the age of 14 she sought medical attention from a female doctor but was sent home as her husband needed to collect the results for her the husband never told her what was wrong but started seeking financial solutions to pay for the medical treatment extract 6 i got married when i was twelve years old a few years later i gave birth to my first son i faced a lot of problems giving birth to him… a woman from work was a doctor so she took me to dhaka medical hospital there they did some tests and noticed that my kidneys were failing she gave me an injection and told me that i had to go home and ask my husband to meet with her then she gave me some pills and sent me home i told my husband that he should go and met with her she was the one who notified my husband about my kidney failure but she never told me what was wrong my husband looked worried when he returned home so i tried to find out why but he never told me what was wrong he just started to work really hard saved up money and even took out a loan the family i worked for at the time also gave us some money … at one point when i was sick and he could not do enough he even thought of selling his blood but i warned him not to do so he does not have that much blood so he would surely have died if we are both dead then who would look after our children in his financial efforts and because of a workrelated accident he develops health issues of his own the family is forced to take out a loan to cover the medical expenses ultimately the husband considers selling his blood the wellbeing loss is experienced by the entire family the parents worry about whether they will survive to raise their children while the children are terrified of losing a mother as well as a father in the session the mother explains how in her childhood her own household struggled with poverty and health loss her parents saw no other option than to marry her away at the age of 12 they could not afford to keep her in the family she was married off to alleviate for the household the intergenerational cycle of poverty health and wellbeing loss is complete her boys may similarly need to leave school and start working if she has a daughter she may be forced to marry while still a child life in the informal settlements goes hand in hand with poor dwelling and work conditions that contribute to health and wellbeing loss that can stretch over an entire lifetime and sometimes beyond some people have to spend their income on medicine or medical treatment others are forced into debt or child marriage to cope these wellbeing losses impact entire families but hit women and children hardest it becomes a vicious cycle of poverty aggravating physical and mental ill health that must be understood as longerterm structural violence gendered disaster immobility wellbeing loss and healing women and children also faced gendered cyclone risks that adult men did not experience for example gendered social constraints around outdoor swimming for women and girls increased their risk of drowning during floods women also got stuck with their hair and saris or drowned while trying to rescue their children extract 7 10 women die because of their hair and clothing they are also emotionally weak children are always fond of their mothers women cannot leave them during such an event that is why they too become victims of the disaster this gendered immobility particularly impacted unmarried adolescent women and girls poor families feared both alleged and actual sexual assaults on the way to or in the shelters toxic rumours could ruin their daughters chances of getting married and financially impact the entire household some families therefore considered it safer for girls and unmarried women to stay behind and wait out the cyclone at home extract 10 it is not right for unmarried women to go to the shelter because it could create problems … i do not like women going to the shelter it just does not feel right wherever they go things happen the economic and noneconomic losses that women and children experienced during the cyclones included wellbeing loss and its relation to domestic tensions extract 11 besides the mental traumas that they leave behind the worst impact upon people is the loss of human lives on an annual basis money and time can reduce damages but they cannot return a lost life… some internal losses may also take place … during the cyclones some people get injured internally injured within such an important organ that he or she may face complications afterwards they may approach doctors and seek medical treatment in secret but some losses cannot be healed by doctors… people face mental issues because of these traumas family problems arise as a result and they grow larger by each day however when we talk about floods it is often the economy that receives the most importance… the only doctors that came to see us after the cyclone were physical medical specialists they were not able to give mental or psychological support to the victims here the narratives described wellbeing losses and damages as internal injuries in an important organ that could not be treated by general practitioners or doctors these wellbeing losses impacted entire societies but were disproportionately felt by women and children research in bangladesh shows that vawc including sexual abuse increases in the aftermath of cyclones yet mental health provision is often not part of postdisaster and humanitarian responses the lack of mental health support hindered the healing of posttraumatic stress and resulted in serious longterm wellbeing impacts in the absence of appropriate mental health services children turned to play and reenactment to deal with cycloneinduced trauma and fear extract 12 we noticed that some children would bury their toys after here and there … from the childrens behaviour we sensed their fear they often repeated when will the flood strike again will i have to go to the shelter again then or will i die next time if it happens again then please promise me not to leave me…the parents reassured their children that the flood will not come back and that they should go back to living life in the way they had done before the disaster stroke many adults turned to religion as a source for healing the belief in a higher power helped people deal with climate uncertainty and loss extract 13 11 when i think about why i survived that day the day of sidr why i did not drown although the flood pulled me away there is only one answer allah looked after me allah kept me safe people put their faith in gods hands and in their power to protect and save those who believe religion provided a belief system that emotionally and psychologically helped people carry on living with the cyclones we feel that religion and cultural traditions must be better incorporated in inclusive adaptation planning that support peoples management around climateinduced loss and grief the case of the fiji islands women and children at risk of violence fiji is a highly vulnerable sids located in the south pacific due to seasonal and interannual climate variations the countrys 18000 km 2 is spread across 332 islands whereof 110 are inhabited the majority of its 912241 people live on two large islands viti levu and vanua fiji faces various environmental challenges that represent major obstacles to achieving the outlined economic and developmental goals sealevel rise ocean acidification floods and the spread of vectorborne diseases have been documented across fijis settlements annual floods tropical cyclones storm surges and coastal inundation significantly affect its gdp growth the largest cyclone to hit fiji was category 5 tropical cyclone winston in 2016 that impacted over 40 of its population caused a us 2 billion financial loss and killed 44 people vawc is reported to increase during and after cyclones in fiji according to humanitarian response workers for example 2021 saw an outcry across the country after a 10yearold girl on vanua levu was raped by her uncle while seeking safety in a shelter during 2020 cyclone yasa the uncle was sentenced to 14 years in prison for the sexual assault as well as a previous rape that took place when the girl was 6 years old according to reports overcrowded shelters and lack of privacy create unsafe shelter conditions for women and children many lavatory facilities cannot be locked lack doors or have windows that provide insight adding to this emergency and disaster responders are not trained in identifying signs of abuse and therefore fail to identify and prevent further violence the 2020 yasa incident was not an isolated event previous records exist of women experiencing domestic rapes in overcrowded shelters or children being trafficked for sexual purposes after the fiji floods it is estimated that 7 of fijis gdp is lost to gbv where a study estimated that 94 of child abuse survivors and 70 of reported rape cases occur in the context of a known perpetrator the narrative sessions also captured unprobed experiences of sexual and other vawc in the context of natural hazards genderbased and sexual violence during disaster events women and children generally face disproportionate disaster impacts due to inherent and socially constructed power hierarchies cyclone winston approximately affected 120000 children whereof 36000 were under the age of five another 5600 pregnant women were impacted and an estimated 600 births took place a few months after the cyclone strike the country battles one of the worlds highest rates of domestic abuse which is far above the global average of 35 a national study involving 3193 women showed that 72 suffered da whereof 61 physical violence 54 emotional abuse and 34 sexual abuse a striking 16 had been sexually abused before turning 15 and most by a family member or a close friend vawc in fiji as elsewhere is clearly not caused by the natural hazards but based in deep rooted structural power inequalities that may increase with societal financial environmental or political pressures extract 17 there is already an unequal distribution of responsibilities within households and the family climate change and floods aggravates the dynamics of such a family women are always affected by disasters the men get aggressive women are more prone to violence when food is not provided women are the poorest of the poor and because of this women are affected by disasters and climate change as they do not have the financial capacity to adapt to the floods cyclone winston acted as a trigger and occurrences of sexual and gbv increased during the disaster as with 2020 cyclone yasa and the 2009 floods women reported how overcrowded spaces lack of privacy electricity and light placed them at risk extract 18 12 women are more vulnerable to genderbased violence in the wake of cyclones in tents and makeshift shelters theres a lack of privacy and proper lighting which makes it harder to stay safe extract 19 another way it affects women and girls is through their displacement to flood evacuation centres from homes in fiji most of these evacuation centres are in schools or community halls which cannot adequately cater for female reproductive rights the evacuation centres are not able to take care of pregnant women and females undergoing a menstruation period because of the traditional and cultural setting of fiji women are unable to speak about these issues with others and they usually have to take care of their reproductive needs in isolation or at night in evacuation centres the cyclones and floods saw increased rates of da correlated with distress trauma and sociofinancial pressures after winston a female member of the parliament stated that women were partly responsible for da leading to a clarifying speech by pm bainimarama at the 2016 world humanitarian summit in turkey 13 this is one way that vawc is kept alive through a framework of power and control women and children are controlled and locked into positions of submission through the reproduction of attitudes framing victimsurvivors alone as somehow responsible for the experienced violence many disaster and humanitarian stakeholders as well as policy makers have thereafter tried to transform such social attitudes and values guide for referrals of gbv survivors as well as unwomen 2015 2023 and the equality institute and un women 2023 extract 22 14 do not touch children without the permission of their parents or unless they are hurt … by doing this you are encouraging pedophilebehavior…and not setting a good example …also stop using children for photo opportunities and do not increase their trauma when you take supplies into the communities dont try to be photographed with it think about the peoples trauma they are going through a lot increased incidents of vawg were reported during and after disasters but it is important to outline further vulnerabilities by other intersectional positions for example elderly women young girls or women and girls living with disabilities are disproportionately impacted as natural hazards do not cause sexual exploitation and violence but can increase intensify or trigger existing dynamics of violence as part of a network of interconnected casual factors we need to analyse the systemic risks around wellbeing loss as a system children living with disabilities were for example identified as a particularly vulnerable group in a study investigating sexual exploitation in fiji extract 24 a father raped his 15yearold daughter who was confined to a wheelchair the father had dug a hole from the outside of their house to her bedroom on the pretext of providing her with a toilet facility at night he would crawl through the hole into her bedroom and abuse her she reported the abuse to her mother but was not believed later she reported it to the police who initiated investigations the girl was placed in the care of the social welfare department and the case was taken to court however the mother withdrew her statement even though there was enough evidence to convict the father the family also turned on the victim blaming her for the abuse the girl lost her case she continues to reside in a care facility extract 25 a pregnant fifteenyearold indo fijian girl who was suffering from downs syndrome and severe dyslexia was brought into the scf office by her brother seeking financial assistance both of her parents had passed away she had dropped out of school at class four after her teachers noticed her slow progress in class but could not identify the cause her brother a heavy grog drinker had befriended their neighbor an indo fijian male who was in his late twenties at the time this neighbor was a frequent visitor to the girls house for grog drinking sessions with the girls brother he later began to visit the girl when she was alone at home a sexual relationship developed between the two and resulted in the girl being impregnated scf found out that the girl went on the suffer a miscarriage but damage for her had already been done in the form of the stigma she suffered at the hands of her family for falling pregnant to the next door neighbour out of wedlock as a result she took to the streets and earned her living as a prostitute however she has since been successfully integrated back into her family by a womens group who found her on the streets and conducted extensive rehabilitation work with her this represents an important gap in the literature on climateand violenceinduced wellbeing loss people living with disabilities seldom represent the main study group in climate change research and less so children living with disabilities 15 as women and children are more likely to experience sexual exploitation due to inherent gendered power relations which likely increase with environmental and financial pressures we believe that this represents an area of noneconomic wellbeing loss that currently remains largely undetected women and children with overlapping intersectional positions of marginalisation such as young poor girls or boys living with disabilities are also likely to be at an increased risk of rape and child sexual abuse in the shelters which longer term may lead to child marriages primarily for the girls as in bangladesh but also human trafficking for girls and boys due to the increased commercial opportunities in fiji extract 26 in the dark they have to go out and this places women in unsafe conditions in evacuation centres women and children get exposed to sexual dangers childrens rights are ignored in this country disaster management is not a very quick recovery for women and children after winston sexual assaults as well as human exploitation featured in the media describing how women and girls were forced into prostitution or coerced into sex for food financial losses forced girls out of school and into child marriage natural hazards often disrupt social and legal order making it a particularly dangerous time for children who experience neglect abuse and exploitation as fiji is a frequent destination and transit country for child trafficking and sexual exploitation this represent another largely unexplored area of climateand violenceinduced wellbeing loss the child sex industry is often facilitated covered up or embedded into regular tourism and postcolonial continued exploitation which makes it harder to combat this represents another area of research into climate and violenceinduced wellbeing loss coupled with the influences of international humanitarian disaster response that remains relatively unexplored extract 27 a network of young schoolgirls involved in prostitution operates out of the motel in which i work how this network works is that if clients want young girls when they come to the motel then they tell the receptionist what type of girl they want and come back the next day in the meantime the receptionist will get in touch with whichever one of the young girls closely matches the description contact is made on the girls mobile phone the girl will come into town the next day change out of her school uniform then come up to the motel to wait for her client extract 28 a single mother of four living in a squatter settlement in suva sought the assistance from scf for her childrens education after a while she requested that her children be removed from the program because she had married an australian man who was going to adopt her children the woman moved her family to nadi to live with her new husband one year later the woman returned to our office and told the scf staff an alarming story her new husband had moved the family to australia and upon their arrival they were held captive in his house she told me about the sexual exploitation of her oldest daughter who was allegedly drugged and gang raped by her step fathers friends this incident was filmed in the presence of her other children the woman was too scared to go to the police and lived in fear whilst in australia she and her children eventually fled australia with the help of a neighbor the oldest daughter is now involved in prostitution in nadi while there was no further evidence of her account of exploitation we saw the scars of what looked like needle marks and cigarette burns on the woman and all four of her children in recent years several asian countries have pushed back against western child sex tourism leading travelling child sex offenders who have identified convenient loopholes in the law to turn towards the pacific tourist locations such as nadi our coastal study site have seen an influx of internally trafficked children due to the new perpetrator demands from australia new zeeland the usa and europe the hidden burden of gendered dependence the research sessions suggested that food insecure women and children faced an increased risk of violence and sexual abuse in the aftermath of disasters this inherent vulnerability traces back to patriarchal gender roles power imbalance and dependence often due to a lack of access to financial resources a framework of power and control helps us reveal how gendered dependence locks marginalised groups into continued patterns and exposure to structural violence male gender roles carried the economic burden of providing for families which could hinder womens livelihood engagement meanwhile women were socially pushed towards food suppliance through supporting roles in subsistence farming and coastal fisheries children would plant or sell vegetables or sea produce after school and during school holidays these gendered dynamics form the basis of income and subsistence within most fijian households and societies as natural hazards impact the productivity of rivers fisheries catchments and agricultural land or gardens women faced losses of basic services and food supply extract 29 people cannot buy groceries groceries become expensive old stock and poisoned food are sold that is when the health inspectors check the food supplies they tell us not to buy such food so some poisoned foods and spoilt ones are thrown away poor people collect the poisoned food but fijians from squatters also collect the poisoned food this pushed women and children to inner reaches of mangroves or outer areas of shorelines in search for river and marine fisheries municipal markets remained closed long after the floods forcing women and children to sell their produce on the streets while exposing them to physical and sexual harassment women remained responsible for childcare and most domestic chores next to the food supply floods and storms often disrupted water and food sources which increased their household workload the labour division during and after the hazards tended to be unequal in the sense that mothers were responsible for the evacuation of children and the elderly needed to look after and care for sick family members clean the house put food on the table and support childrens return to schools while men sought employment the women were left feeling over stretch overworked and tired extract 30 16 women have to clean up the flood they have to decide where to set things women start from the very bottom what to bring in the house after floods and howto setup the house everything has to be done by the women from cleaning the house to finding food and taking sick children after floods to hospital rising sea levels and coastal erosion has led the government to begin relocating and resettling its population several villages are at some stage of a relocation while another 157 page 20 of 34 42 villages have been earmarked women and girls were often excluded from the relocation decisionmaking and expressed more adverse sentiments related to attachment and identify loss heightened fear and health impacts relocation from the coast to higher ground or household and caring chores also excluded women from their coastal fishing resources while increasing their dependence on men for food extract 32 as soon people hear about floods they run to higher places women take the children to hospital and schools husbands stay behind in house people put their vehicles in higher places the meteorology office and news tell people quickly so deaths are reduced climate is changing there is more rain the earth cannot soak so much rain which is a lot now days nadi female religious leader 37 18032010 women expressed heightened anxiety and sadness around losing their local ecology fear for the younger generation hopelessness and helplessness the anticipation of the next disaster fear and traumatisation often echoed through the villages climatic changes left traditional knowledge and natural early warning systems less reliable the feeling of eroding knowledge and reduced access to climate information further heightened womens insecurity and dependence people associated natural hazards with the death of family members loss of livelihood and income belongings food and water or hunger suffering and increased crimes psychosocial distress was triggered by intense rain cyclone and flood warnings that forced people to evacuate and seek shelter on higher grounds women and children of particularly vulnerable intersectional positions such as poor women living in informal settlements or marginal farming societies experienced additional fear when evacuating and leaving their homes to seek social assistance poor farmers and small business households were anxious about leaving their limited possessions and belongings behind women were also apprehensive about voicing their maternal and reproductive health needs stark examples of the gendered psychological impacts of disasters were provided by the fijian case study vawc intensified with the disasters and yet many research gaps related to climateand violenceinduced wellbeing loss were identified structural power inequalities and social reproduction of gendered dependence continue contributing to vawc studies in disaster loss must better incorporate a framework of intersectionality and power and control to better understand the interconnections between climatic changes violence and mental health losses and damages the case of vanuatu stories of gendered hardship and recovery vanuatu is an archipelago in the south west pacific of 83 islands inhabited by approximately 300000 people the countrys high disaster risk has consistently been ranked by the world risk reports the sids is ranked 131 out of 187 countries in the human development index and its people are often portrayed as poor and vulnerable however vanuatu societies paint a contrasting picture of strength persistence knowledge kastom and pride marketplaces are a crucial source of income for households across vanuatu and women make up most marketplace vendors the dependency on climatesensitive crops would lock households into a system that is disproportionately sensitive to shocks womens voices experiences and needs are often minimised ignored and neglected at both micro and macro scales despite their wealth of knowledge and capacities stories of loss gendered dependence and hardship many marketplace vendors emphasised the livelihood risks posed by cyclones and droughts through experiences of loss and hardship 2015 category 5 cyclone pam was the worst cyclone to have hit vanuatu causing deaths displacing around 65000 people and impacting 80 of rural livelihoods including 96 of the food stocks the women described pams devastation on their gardens homes infrastructure and livelihoods extract 33 all the things from the garden went down house also gone away almost 10 houses in the village … everything like coconut and mangos and crops all the nuts everything … theres nothing there until today all the mangos are still not havent bared fruit women first had to try and clean their homes and go to the gardens to see if anything could be salvaged for their families to survive over the coming days and weeks the destruction made it difficult to access the gardens extract 34 they found it very difficult to enter the garden because all the woods are blocking the entrance to their garden you had to go over the garden or go over the big trees once the men were able to clear the garden entrances and remove the large trees the women returned to their gardens to start the cleanup and replanting this process had a significant impact on their ability for selfsubsistence and their livelihoods given that selling fresh produce and handicrafts at marketplaces was what they did to support their family women felt unable to provide food to the household which resulted in wellbeing loss and made them feel dependent on men cyclone pam significantly impacted womens lives by haltering marketplace operations for months and for some over a year extract 35 after clearing the gardens plant and it took them one year to actually come back to the market and start selling later that year the worst drought in 20 years hit people who were barely recovering the reoccurring hazards significantly reduced womens wellbeing it was described as a heartbreaking experience the crops are all destroyed for many women growing crops after pam was critical to their familys survival and a gendered responsibility women felt that tending to crops that were brought back home was a way to express care for their children husbands and the wider family this represented a grave loss as the drought dried out the crops or stunted them after this women began to rely on fewer more droughttolerant crops such as manioc and taro stories of recovery and hope stories of recovery and healing for women in vanuatu revolved around social networks changing agricultural behaviours and diversifying livelihoods to build a more hopeful future women worked together as a unified collective which in time of crisis was particularly pertinent their social networks extended across islands which served as a useful resource in times of produce shortages women from different islands were useful in overcoming issues with peripherality the social connections also acted as safety nets when women temporarily faced low stocks the social resources were described as crucial to recover from pam extract 36 she makes orders to other islands to other women so family members that are in paama or ambrym that have nuts or epi… they send it over to her and then she resells it and gets her money but she pays them oh they do exchange with food they package them a box of food for that muma and that muma sends things over women were also agents of social change by ensuring equity and inclusiveness in disaster recovery by consistently helping and involving those less able in the gardens and marketplaces after pam an important change in practice among women was the decision to save seeds given the lengthy wait for supplies to arrive after pam including seeds and tools women proactively began to collect seeds following each harvest another agricultural adjustment applied by the women related to keeping smaller plantations and having multiple gardens near the home extract 37 17 i know that if one disaster comes now ive saved some seeds … dont wait for external assistance as a way of recovering from and preparing for a more hopeful future women spoke with excitement of diversifying their income sources by becoming entrepreneurs page 23 of 34 157 extract 39 i paint fabrics and then i sew them the dresses and they have built businesses at their homes little canteens extract 40 it really impacts the life of women in the community they are doing businesses like food selling handicraft they are doing printing painting and all this stuff just for money before they came back to their communities and they do the same thing as well this is a very big change that ive seen vanuatu illustrated important narratives of womens strength and persistence the storylines portray women in a refreshing light seldom seen within female disaster representation womens social vulnerability due to power inequalities must be acknowledged without portraying them as helpless and passive victims these unhelpful gendered stereotypes build expectations of women as glorified perfect victims which represents an unreachable position for any human being by instead acknowledging womens vulnerability in gendered dependence but also their strength and innovativeness in disaster preparedness their role is elevated and celebrated in vanuatu socially reproduced female traits such as inclusive disaster responses and caring for the weak were presented as strengths women were active enablers of recovery and their disaster responses societal rebuilding and collective healing strategies must be shared as sustainable disaster response practices these stories of loss gendered dependence hardship recovery and hope are important illustrations of how women stood proud on the disaster frontlines while collaborating and collectively sharing knowledge and skills within their social networks these women illustrated holding diverse and innovative social resources to rebuild what was lost and damaged while also aiming to address the underlying root causes of vulnerability such as the inequitable power structures that erode womens and societies wellbeing discussion research into climateinduced wellbeing loss and despair is not new studies exploring such experiences however often describe male loss of productivity and natural resourcebased livelihoods such as farming and fishing distress in the context of environmental changes is a global occurrence that nobody can escape societies may adapt but their strategies often include irreversible losses values or tradeoffs this article explored spiralling noneconomic losses in the context of vawc and mental health that eroded womens and childrens wellbeing while impeding coping risk reduction and adaptation actions women girls and boys face patriarchal risks stemming from societal gender inequity that adult men will not experience in the same way the identified noneconomic wellbeing losses were shaped by structural violence such as unsafe living or work conditions systemic food and employment insecurity or control dependence and loss of decisionmaking and agency an important finding from fiji was that experiences of structural vawc targeting particularly marginalised intersectional positions intensified during and after disasters structural vawc should not be blamed on the hazards nor should it be understood as unique to fiji research in bangladesh found similar vawc trends where young unmarried women and girls feared sexual assaults while da and child sexual abuse also increased in the aftermath of cyclones and floods research findings of genderbased and sexual violence in the context of natural hazards have emerged from countries including the usa pakistan and several countries in southern africa but we still require a greater incorporation of intersectionality into these research studies poor migrant indigenous ethnic minorities elderly children lgbtq or people living with disabilities are rarely the core study group in most climate change investigations further to this among some policy circles vawc including child sexual abuse and exploitation appears to remain a somewhat taboo subject we are yet to see an ipcc chapter or a unfccc report outlining the connections between climate change vawc human trafficking and exploitation and loss and damage women and children are more often exposed to rape and sexual exploitation as well as physical and emotional abuse than adult men vawc leaves deep wellbeing scars that may not even heal within a lifetime unlike material losses the wellbeing impacts upon women and children that are interrelated with vawc tend to leave longlasting and intergenerational mental health challenges empirical evidence from the two island settings indicated the heightened distress in women extending from dependence and control around their gender roles in our gendered societies food preparation is often a female responsibility in fiji food loss in periods of disasters compounded social household tensions increasing the risk of vawc in vanuatu women felt inadequate after losing their gardens that represented individual selfefficiency independence agency and ability to endure and recover the loss of social safety nets or control over food and natural resources also introduced coercion into prostitution exploitation through food for sex or child marriages as we noted in bangladesh the decision to marry off a child was a family loss that impossibly can be measured in monetary terms noneconomic losses and damages are often characterised as difficult to estimate and quantify or valorise the article delicately illustrates that it is impossible to compensate or quantify loss of dignity human value or lack of respect from society these irreplaceable losses in the case study countries although context specific and associated with sociocultural values followed similar structural gender and power systems the gendered dimension of climateand violenceinduced loss and damage is highly subjective but closely mediated by our societal regulatory systems such as equity justice rights welfare and basic services peoples subjective and intersectional understandings of loss and healing were built into local narratives that provide policy with key insights of the values related to losses coping around irreplaceable losses and what damages remain thereafter the uniqueness of life experiences cannot be incorporated into standardised measurements statistical or economic assessments but they can act as steppingstones to support adequate risk reduction efforts in vulnerable locations and among marginalised populations narratives around recovery and healing emerged that represent research needs to be prioritised in the future an enhanced understanding of how people recover from the grief loss and heal can provide valuable tools of howto best support more inclusive policy policy must better incorporate counselling assessment of damage and wellbeing erosion page 25 of 34 157 local understandings of psychological care and mental health services for trauma to appropriately support marginalised people in vanuatu support groups of women in the marketplaces shared the emotional and psychosocial burden similarly in fiji in the absence of formal psychological care womenled support groups enabled recovery by exchanging stories about trauma and by collectively gathering strength the narrative analysis found an urgent need to create safe spaces for women and children in disaster contexts this goes far beyond safe shelters to include strengthening social safety networks building culturally appropriate counselling and mental health services and caring as part of climate and disaster planning to minimise and address future losses and damages postdisaster mental health and psychosocial support services are often inadequate leading to societal mental health challenges for several generations to come the preservation and continuity of cultural practices are key in disaster recovery as local and cultural traditions provide important skills and selfreliance that help strengthen identity formation and feelings of social belonging this can reduce social dependence and unhealthy power structures which in turn may reduce and help combat vawc conclusion the idea of limits to adaptation provides a basis for ways to measure loss and damage yet in the context of noneconomic losses limited efforts have been devoted to the design of methods that capture mental health loss among marginalised and vulnerable groups to fully understand the consequences of gendered climateand violenceinduced noneconomic losses and damages bottomup and peoplecentred storytelling approaches will be needed climate change action must better leverage the various benefits of storytelling approaches that include improved mental health assessment of gendered needs cultural belonging identity and collective histories life experiences effectively support the muchneeded local insights and evidence around loss and damage peoplecentred climate change research still receive little attention as the general idea appears to be that the right set of normative indicators will be the panacea for all disease we must also transform our perceptions of losses and damages as something environmental such as in the loss of land crops livestock and food to include a wider climateviolence nexus that incorporates everything from child marriage sexual violence coercive and controlling behaviours and gendered dependence to human trafficking and exploitation our understanding of the causes and triggers to societal and psychological loss and trauma must extend from the environment to the sociopsychological relations with the environment these associated mental health impacts may pose longterm consequences leading to intergenerational wellbeing losses for entire societies countries and regions in a climate changed future national and global policy frameworks that aim to address noneconomic losses and damages must better prioritise women children and other intersectional marginalised groups a stronger acknowledgement within climate policy must accept that losses and damages to mental health wellbeing and dignity cannot and should not be measured in monetary markets certain elements in life are invaluable and the fact that we do not attempt to measure them is precisely what gives them a unique value data availability primary data available upon request consent to participate all research participants have agreed to take part in the study through written informed consent conflict of interest the authors declare no competing interests open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to the creative commons licence and indicate if changes were made the images or other third party material in this article are included in the articles creative commons licence unless indicated otherwise in a credit line to the material if material is not included in the articles creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use you will need to obtain permission directly from the copyright holder to view a copy of this licence visit creat iveco mmons org licen ses by4 0 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations authors and affiliations sonja ayebkarlsson 123 • alvin chandra

it is wellknown that women children and other intersectional and marginalised social groups are disproportionately impacted by noneconomic wellbeing loss in the context of climatic changes however few empirical studies investigate its interrelation with violence against women and children vawc we urgently need to widen our perceptions of what falls under the umbrella term noneconomic loss and damage nel d s for societies to appropriately be able to avert minimise and address losses and damages among vulnerable people through stories of loss and healing we step into the realities of women and children who illustrate how they experience noneconomic wellbeing loss within a climateviolence nexus in bangladesh fiji and vanuatu a storytelling and systems approach guided the analysis of personal narratives gathered through a secondary data review and empirical field work the research findings identified different pathways through which womens and childrens mental health was compromised in the context of structural violence and climatic risks in bangladesh the narratives described wellbeing erosion in the context of gendered im mobility in fiji the findings captured womens and childrens experiences of sexual violence domestic abuse exploitation and trafficking in the context of natural hazards while in vanuatu hardship gendered dependence and healing were narrated by women in their stories surrounding disaster recovery this article comprehensively lays out the longerterm societal wellbeing consequences of climatic changes and genderbased violence it also identifies research gaps in need of further attention and proposes policy recommendations as well as methodological and disaster health service solutions to address wellbeing loss in a climate changed future

background the rural health workforce in australia is ageing and is older than the urban health workforce 1 2 3 4 in 2005 the average age of nurses in outer regional areas of australia was 460 years compared to 446 years in metropolitan areas 2 although younger than the nursing profession rural allied health workers also tend to be older than their city counterparts 3 both the nursing and allied health workforces are predominantly female at around 75 4 for the hunter new england area health service in northern new south wales around one quarter of allied health workers and a half of the rural nursing workforce were aged over 50 years in october 2009 this a pattern likely to be shared by other rural health services across australia workforce sustainability at least in the short term is likely to depend on nurses and allied health workers being willing able and happy to work beyond middle age ageing is associated with recognised physical and mental changes including reductions in aerobic power muscular strength and endurance reaction speed acuity of special senses difficulties with thermoregulation sleep disturbances and concerns about increased risk of chronic illness 5 6 7 8 back pain other musculoskeletal disorders and stressrelated mood disorders are common health and injury problems with older health workers 910 however in some studies older nurses and other older workers have been shown to have better than average physical and mental health although this may be because work helps keep older workers healthy or less healthy older workers leave the workforce 911 generally speaking in the absence of major illness little relationship has been found between ageing and work performance per se 5 12 13 14 personal health and fitness however can be highly variable amongst older adults and is more likely to affect physical strength and likelihood of injury than ageing itself 512 poor health is strongly associated with labour force exit 15 16 17 whilst older workers have considerable capacity to manage job demands and difficulties it has been suggested that at some point older workers do become overwhelmed by the increased risk of health consequences injury and disability 18 recruitment and retention of health professionals of all ages has proved an ongoing difficulty in rural areas this is related to an interplay of personal environmental and wider workrelated factors professional isolation lack of recognition limited access to professional education high workloads and stress related to lack of replacement staff long work hours limited resources and sometimes unsupportive management practices are commonly described workplace challenges 3 19 20 21 22 given the proportion of rural health workers aged over 50 years the question to be addressed is whether there are specific difficulties for older workers on a day to day basis in addition to the challenges faced by all health workers specifically this study aimed to identify work tasks and broader challenges that have become more difficult for rural health workers as they have become older and the factors that contribute to these difficulties findings are informing the development of solutions at personal workplace and systemwide levels in an ongoing action research project methods this qualitative research project used a focus group methodology and thematic analysis to identify and interpret issues arising from workshop discussions participants were also encouraged to reflect on issues provide further input and act locally on ideas whilst the wider research was still in progress consistent with qualitative action research principles a project reference group was established prior to commencement of the workshops which consisted of the two researchers and eight health service personnel these included health service managers rural nurses and allied health workers currently working within hne health prg members were nominated by the hne health executive team on the basis of particular areas of practice location responsibility or expertise relevant to the project the purpose of the prg was to provide practical advice and assistance on the conduct and direction of the project provide feedback after the initial workshop and to review and provide practical comment on preliminary results and recommendations communities were selected to host a focus group or workshop on the basis of size and geographic spread across the hunter new england region of rural nsw each workshop was held in a town with a population between 5000 and 30000 people communities were located in six of the seven rural management clusters of hne health local health service managers or their representatives were contacted to assist in arranging the workshop and to make sure all health service staff knew about it notification of each local workshop with an invitation to participate directed at staff 50 years and over was circulated 23 weeks in advance through regular workplace communication channels this included staff email networks staff meetings staff notice boards and wordofmouth health service managers in communities within an hours drive of the hosting health service were also asked to inform their staff about the workshop a convenience sample of 80 older health workers attended the six workshops between august and november 2008 four were men and an average of 13 participants attended each workshop demographic information on the age and characteristics of individual participants was not collected but each group was asked to indicate their general work experience and fields of practice consistent with an over 50 cohort a number of participants had worked within the health service for 30 years or more participants were mainly drawn from the nursing and allied health professional groups who were the focus of recruitment efforts allied health fields of practice included radiography occupational therapy diversional therapy physiotherapy social work and psychology nursing sector participants included registered nurses and enrolled nurses from community health aged care general hospital wards operating theatres sterilising departments midwifery emergency departments and health service management a small number were from other professional groupings encompassing other professional paraprofessional and clinical support staff corporate services and hotel services the majority of participants worked regular office hours although others had worked shift work in the recent past participation was completely voluntary and informed consent was obtained from participants prior to their involvement at the outset of each workshop the purpose of the research was explained to participants by the lead researcher who acted as the group facilitator a participant information sheet was provided outlining further details and after opportunity for questions participants were asked to sign a formal consent form prior to commencement of discussions within each workshop participants were asked to identify and describe • work tasks and aspects of work that have become more difficult for rural health workers as they have become older • agerelated changes and other exacerbating factors contributing to these difficulties responses focusing on these questions were recorded by participants during small breakout groups of 35 people in particular participants were asked to list difficulties in a table and to record ideas on the agerelated changes and exacerbating factors that contributed to each of these difficulties in an adjacent column one or two items from each small group were selected for further discussion by the larger group enabling other group members to contribute andor debate ideas one researcher had the designated task of taking detailed notes during the course of these larger group discussions which supplemented the data recorded by participants on the small group worksheets thematic content analysis was then used to identify issues arising from workshop discussions notes and worksheets were reviewed after each workshop and information sorted into categories that focused on defining difficulties associated with specific tasks variation within work contexts and relationships between categories categories were progressively reviewed and used to help guide discussion in subsequent workshops until no new information on the subject arose themes relating to difficulties were tabulated moving from particular tasks and specific workplace settings to more general aspects of work and broader settings participants were invited to reflect on ideas shared in their workshop and act locally on issues whilst the wider research project was still in progress preliminary findings from all workshops were sent to participants who were given opportunity to provide further feedback and ideas prior to final recommendations being made the research protocol was approved by the hunter new england human research ethics committee this was consistent with local health service requirements and research ethics principles of the world medical association declaration of helsinki 23 results challenges in particular work settings the following tables indicate specific tasks and challenges in a range of work settings that older rural health workers reported as becoming more difficult with age work and agerelated factors that contributed to these challenges are also presented work in the hospital setting that has become more difficult for older workers includes reading medication labels this is exacerbated by poor lighting small print size and print colours such as orangered print on ampoules used for injections hearing difficulties are exacerbated by high levels of workplace noise and for some by the accents of staff from nonenglishspeaking backgrounds manual handling and manoeuvring of patients was particularly difficult where squatting bending or maintaining postures for long periods was required it was also considered more physically challenging because patients were getting older more debilitated and overweight patients are older and heavier and so are we shift work was met with increased tiredness with an expressed need for longer recovery times between shifts disturbed sleep and anxiety about lack of sleep was commonly reported with problems of tiredness sometimes exacerbated by a lack of replacement staff it takes 2 days to get over a double shift you cant go off sick theres no one to replace you specific clinical procedures such as physiotherapy exercises are also more difficult because they often involve long periods of leaning bending and being on ones feet midwifery had become more of a challenge for older midwives partly attributed due to the increased birthing options and positions for women i think reasons why some older nurses no longer practice midwifery challenges facing older community health workers are described in table 2 community health workers described greater driver discomfort and fatigue now they are older getting in and out of vehicles was more difficult especially with the purchase of smaller lower cars carrying equipment to and from vehicles and moving around in cluttered homes has made home visiting more difficult the are too low you have to roll out of them work with computers also poses a particular challenge for older health workers the problems relate to physical discomfort associated with sitting for long periods keyboard dexterity and seeing small font on screens additionally there are mental challenges associated with the rapid adoption of new programs the need to remember passwords and interpretation of computerised results little previous exposure and a general lack of confidence with computers was a commonly reported experience it was also felt group training sessions were mostly levelled at a younger more computer literate generation it trainers assume a skill level that is not necessarily so some have even left because of the computers or some cant work in emergency department because they cant use the computer participation in meetings conferences and education programs often requires long distance travel and night driving this has become harder now that participants are older due to driver fatigue musculoskeletal problems and difficulties with night vision these issues are exacerbated by a lack of adequate back support in vehicles glare of lights and bright road signs alternatives such as teleconferencing also pose problems for the hearing impaired once upon a time i could get in a car and drive to a meeting at the end of the day now i cant do that challenges spanning work tasks and settings table 5 indicates the more general challenges associated with age and work within rural health services these difficulties span across work settings and particular tasks participants felt that meeting overall workplace demands across settings had generally become more difficult as workers have become older mental fatigue is occurring from a sense of information overload and an expectation to have stuff in your head increased paperwork requirements and having multiple roles within the health service are contributing to a build up of mental stress making it difficult to concentrate amidst personal challenges reported by older workers include coping with change such as increased role complexity more hats to wear and greater administrative requirements a new system every year you learn it then it changes again this is reportedly worse when older workers organisational wisdom about change and what has worked in the past has not been sought or valued new ideas were sometimes perceived as reinventions that led to more work more stress and little perceived benefit what goes around comes around a revolving door of ideas youve done it before and nothing ever came of it emotional stress following acute care episodes or death of people has also become much harder to cope with with workers often knowing people personally after years of caring for them participants also reported a greater sense of empathy attachment loss and an increased awareness of their own ageing and mortality the death of older people affects us more as we age ourselves theyre closer to our own age now now you know them theyre not just a patient balancing work with family life commitments is another challenge many described having an extended carer role within families for ageing parents partners grown up children and grandchildren this could involve travelling long distances for health and family matters participants expressed a desire to work less or more regular hours or have time off to attend to these responsibilities however they felt management often did not understand this need or that there were not enough workers available in small rural health services to enable this participants were keen to make a positive contribution to good health care in their community and believe they were doing so however at the same time many felt they fall short of achieving personal standards related to care or in fulfilling the expectations of patients the organisation and peers this was attributed to high workloads reduced clinical time increased administrative tasks and a sense they could not get done in a day what they wanted or were expected to do participants felt this was worse for older workers because they were slower than they used to be yet had a high work ethic and pride in delivering quality care its not the work you do its the work you cannot do that is frustrating and emotionally distressing and results in less job satisfaction given this context some expressed a lowered tolerance for uncooperative rude or aggressive patients or those who wont help themselves conversely some felt that life experience gave them a more empathetic view than when they were younger participants in each workshop were offered the opportunity to suggest potential solutions to the problems that were identified these solutions fell into three categories recommendations for personal behavioural changes for worksupportive solutions and systemwide solutions such as purchasing of vials with more legible print these ideas are being incorporated into an ongoing actionresearch project by the health service discussion this study attempted to capture a range of perspectives on this issue from older health workers in rural health services across the hunter new england region although it could not be claimed that the views of participants were representative of all older health workers in the area recruitment of individuals was dependent upon participants receiving information about the workshops the appeal of attending a workshop on this issue and available time on the part of managers to encourage local participation and ensure information was received by all health workers whilst provisions were made for work release to attend workshops fewer current shift workers attended workshops than community health staff and others who worked more regular hours also whilst groups were facilitated it is possible some individuals did not feel free to express personal opinions in a group forum and that some individual opinions were not captured by group data collection processes despite these study limitations recurrent themes arose in the workshops relating to broad areas of difficulty with no new themes on the issue emerging by the last workshop ageing changes described by older health workers that contributed to difficulties at work are generally consistent with ageing impacts reported elsewhere 5 6 7 8 in particular musculoskeletal problems deteriorating vision fatigue and reduced fine motor dexterity were common concerns harder to turn around to look behindharder to see out of cars ▪ getting in and out of cars and the day care bus ▪ more fatigued for report writing after driving around during the day ▪ carrying equipment tofrom vehicles and homes eg baby scales exacerbated by ▪ ergonomics of smaller and lower cars hard to get in and out of not comfortable poor seating ▪ day care bus bumping up and down along the road ▪ tight time frames rushing ▪ general safety issues related to night and longdistance driving vision fatigue time allowed work involving home visits agerelated factors specific to these tasks participants were concerned that these difficulties were affecting their sense of personal health and wellbeing a desire for reduced work hours and to spend more time with family suggested an awareness of the impacts of too much work supporting findings elsewhere that the benefits of a healthy worker effect can be compromised by workfamily conflict and excessive work hours 91124 physical demands rotating shifts inflexible scheduling and full time positions are also known to be associated with chronic fatigue and personal health concerns of older nurses elsewhere 6925 however alternatives such as lateral movement of older workers to less physically demanding positions cited elsewhere 102627 are a less likely option for many small rural health services already short of staff in difficulties working with computers were commonly reported supporting findings elsewhere 2829 including the sense that computerised systems did not necessarily reduce documentation time 30 participants were keen to participate in computer education courses given attention to more appropriate adult learning styles a finding also supported by other studies 512 however barriers to education access for older workers not reported elsewhere include difficulties with night and long distance driving and difficulties hearing teleconferencing facilities whilst a sense of community and appreciation of rural lifestyle are amongst the most important reasons given by health workers for continuing to work in rural areas 193132 there is also a greater likelihood that patients in rural areas are known by health workers with emotional implications when wellknown patients suffer or die the grief and emotional impact described by participants of losing someone you know may be a form of compassion fatigue also described as the cost of caring for others in emotional pain 3334 given participants life stage and the rural context compassion fatigue may be part of the fatigue experience of older rural health workers reviewing lifework balance has been reported as a response to working conditions existence of chronic pain ageing and personal issues 10 prominent among personal issues in this study and elsewhere 635 are the demands and complex responsibilities associated with an extended primary carer role outside of workcontributing to a desire to work less hours similar to other studies 1036 participants felt that the perspectives of older workers were often not helpdesk is on the computer not in hardcopy ▪ historicalgenerational learning factors not having computers at home and not growing up with computers computers not seen as a priority learn differently we are more practical people harder for shift workers to adapt to computer ▪ general lack of confidence and support with computers and new technology it support not always available when needed frequency of use affects confidence tendency to avoid new technology due to difficulty with equipment fragar and depczynski bmc health services research 2011 1142 valued by the organisation even though worker participants were generally supportive of the organisation and happy to have been consulted in this study a sense of powerlessness about not having ones opinion heard has been associated with burnout and illhealth in health workers 10 more generally work stress amongst rural nurses has been attributed to a climate of change restructuring and financial constraints that lead to increased expectations or role changes for which nurses are not prepared or consulted 37 this experience may be worse for older workers also dealing with ageing and generational factors that make adapting to change harder as a generation older health workers have been described as committed hardworking intuitive and skilled decision makers possessing a deeprooted understanding of patient needs 62638 however such values may increase the emotional exhaustion and guilt felt when extra stressors related to role change and patient load takes time away from providing the quality care that helps define selfworth 63940 intolerance for perceived rudeness abuse and unwillingness in some patients to help themselves may arise because such behaviours conflict with generational values and because older health workers feel they are already providing quality care under stressful circumstances for example obese patients were regarded as more physically demanding which if combined with a perception that a patient was not trying to help themselves could contribute to or explain some of the negative attitudes toward such patients that have been reported elsewhere 41 however in contrast other participants felt they were more empathetic or tolerant of demanding patients than younger workers a finding also reported elsewhere 4142 generally speaking older health workers displayed a great sense of humour during the workshops and believed their maturity and wisdom gave them a valuable perspective on work and life like older workers elsewhere participants continue to care despite difficulties intergenerational conflicts and less respect from patients 1039 collegial relationships within the health care team have been found to reduce job stress and foster decisions to stay in the workplace 6 whilst poor working conditions lack of supportive workplace relationships combined with ageing concerns have influenced older nurses to make changes for the sake of their own health offered to younger staff in preference feeling of being overlooked for courses youll be retiring soon but a prevailing belief it is more likely older workers will stay in a place for longer ▪ in contrast participants also reported that some workers flatly refuse to gochange or learndoggedness client expectations to remember their names ▪ pressure of meeting several demands at once ▪ longer term impacts always stretched physical and emotional stress less happy less tolerant etc meeting the physical demands of workload as an older health worker agerelated factors ▪ musculoskeletal changes increased pain stiffness ▪ general tiredness and fatigue especially after lunch end of day focusing for long periods ▪ reduced fitness and endurance reduced energy levels and loss of weight ▪ slower physically takes longer to do things including routine tasks cant walk as quickly exacerbated by ▪ a sense there is more to do but not enough time to do everything or do it well ▪ patients are older heavierand so are we ▪ sicker more dependent and debilitated patients coping with change age related factors ▪ subdued mental reflexesagility these may be ▪ procedural ▪ organisational in particular ▪ role changes ▪ coping with change both cognitively and emotionally coping with sudden change ▪ need more time to assimilate knowledgechange ▪ lesslack of adaptability exacerbated byresistance to change due to ▪ constant change referring to the many changes in the health service over the past 15 years eg in systems procedures roles ▪ change often associated with increased paperwork requirements new computer programmes ▪ less tolerance for supposedly new things and reinventing wheels ▪ experience of older workers not valued people dont ask us the opportunity is not provided ▪ casual workers dont always know about changes ▪ in contrast participants also noted that some workers refuse to change or learn doggedness more sensitive to criticism when older negative thinkingspin from others and from self eg im too old ▪ tiredness dealing with difficult situations eg confrontation associated with dealing with destructive and undermining behaviours would rather avoid it exacerbated by▪ attitudes and behaviours of patients organisation younger workers ▪ interpersonal communication communication with younger workers difficult language used seem less compassionate seem to only half listen in contrast not in our team we work well and communicate well beware of generalising fragar and depczynski bmc health services research 2011 1142 10 finding ways to address concerns and avoid excessive demands being placed on older health workers should contribute to a happier healthier and more sustainable older health workforce conclusions this study describes some of the practical difficulties and issues confronting older workers in the hunter new england health region of nsw which are likely to be shared in other regions with a view to developing practical solutions the following recommendations have been made to and accepted by the health service executive team older health workers should be involved in development of a resource booklet on ageing and other factors that impact upon work with practical suggestions for addressing these at personal and local level the health service should establish a health service task force comprising managers older rural health workers and an occupational therapist to examine the study findings and implement areawide policy and practice solutions as well as recommendations for statewide policy development older health workers in rural areas are a committed and productive section of the workforce who are meeting health service delivery needs at considerable personal cost this study supports the view that there comes a point where physical and emotional costs exceed the benefits of work particularly as other realms of life take on more importance but that this is likely to occur more rapidly where stressors and difficulties that are amenable to solution or modification are not addressed actions that health services can take to consult and value the opinions of older workers in addressing these difficulties will benefit not only older workers but will be in the interests of the health service and better health care delivery funding the older health workers project was an internally funded cojoint activity of the australian centre for agricultural health and safety and the hunter new england area health service no specialpurpose or external funds were received or allocated from any other funding bodies research time and labour costs were met under existing funding arrangements by the australian centre for agricultural health and safety competing interests the authors declare that they have no competing interests

background the health workforce in australia is ageing particularly in rural areas where this change will have the most immediate implications for health care delivery and workforce needs in rural areas the sustainability of health services will be dependent upon nurses and allied health workers being willing to work beyond middle age yet the particular challenges for older health workers in rural australia are not well known the purpose of this research was to identify aspects of work that have become more difficult for rural health workers as they have become older and the agerelated changes and exacerbating factors that contribute to these difficulties findings will support efforts to make workplaces more userfriendly for older health workers methods nurses and allied health workers aged 50 years and over were invited to attend one of six local workshops held in the hunter new england region of nsw australia this qualitative action research project used a focus group methodology and thematic content analysis to identify and interpret issues arising from workshop discussions results eighty older health workers from a range of disciplines attended the workshops tasks and aspects of work that have become more difficult for older health workers in hospital settings include reading labels and administering medications hearing patients and colleagues manual handling particular movements and postures shift work delivery of babies patient exercises and suturing in community settings difficulties relate to vehicle use and home visiting significant issues across settings include ongoing education work with computers and general fatigue wider personal challenges include coping with change balancing worklife commitments dealing with attachments and meeting goals and expectations work and agerelated factors that exacerbate difficulties include vision and hearing deficits increasing tiredness more complex professional roles and a sense of not being valued in the context of greater perceived workload conclusions older health workers are managing a range of issues on top of the general challenges of rural practice personal health wellbeing and other realms of life appear to take on increasing importance for older health workers when faced with increasing difficulties at work solutions need to address difficulties at personal workplace and system wide levels

introduction in 2020 the global population aged ≥60 years reached more than 1 billion accounting for 135 of the worlds population additionally increasing life expectancy decreasing mortality rates changing family structure and increasing the percentage of older adults living alone are reported annually in 2021 the percentage of older adults living alone in south korea was 351 older adults who are living alone have worse health status and healthrelated quality of life so they require more social functions and resources from social networks than other forms of living arrangements thus because of this rapid increase in older adults living alone improving the health status and hrqol of this group is becoming a more significant public health issue the world health organization promotes wellbeing through healthy aging which maintains and develops functional abilities in this context social frailty is emphasized in gerontological studies therefore social efforts are required to improve the quality of life including the functional health of older adults living alone hrqol is a broad and multidimensional concept that focuses on an individuals perception of his or her position in life it is affected by physical and mental capacities functional abilities and environmental aspects such as social factors a previous study has reported that hrqol in older adults is associated with sociodemographic factors physical health status nutritional status and mental health however only a few studies have comprehensively investigated the association between health status and hrqol among older adults living alone the who has proposed the international classification of functioning disability and health model which can explain the health health status and quality of life of various population groups living in the community and performing activities of daily life the icf model encompasses not only physical and mental functions but also social functions such as activities and social participation personal factors such as an individuals age gender and socioeconomic characteristics and environmental factors related to personal health and life conditions therefore it is evaluated as a biopsychosocial integrated model that explains health and quality of life this icf model is also used to predict the quality of life of older male adults living alone in our previous study we investigated how health status is associated with the quality of life of older adults living alone focusing on relationships that differ by gender however a regression analysis with a crosssectional design is limited because it can only provide assumptions regarding positive correlations between variables from a specific perspective therefore a longitudinal followup study is needed to be confident of an association based on an integrated model that affects the quality of life of older adults living alone study aim and hypotheses this oneyear followup study from a cohort aimed to examine the changes in health status and hrqol among older adults living alone clarify the associations between health status and hrqol to develop successful public health services and contribute to a deeper understanding of this topic we hypothesized that health status would change after one year hrqol would change after one year and the association between health status the hrqol would change after one year materials and methods study design and participants the study population was derived from a prospective cohort of older adults living alone the primary older adults were obtained from a previous crosssectional study on communitydwelling older adults aged 65 years who were living alone between august and october 2018 in siheung city south korea in august 2019 789 participants underwent a 1year followup examination the participants included in the study were at least 65 years of age living alone in siheung city able to communicate orally and provided written informed consent after excluding participants who were living with others those who did not undergo followup and those who did not complete the questionnaire data from 789 older adults were analyzed measurement general characteristics the general characteristics were divided into the following age because of great diversity among different age groups in late life they can be further categorized as follows youngold 6574 years old 7584 years and oldestold ≥85 gender marital status surviving child education level current religion status economic status and social activity social activity was assessed through participants selfreported responses to the question how often do you engage in social activity participants could select among the following responses none12 times per month12 times per week34 times or more per week health status the participants health status was assessed based on their physical mental and social health the subjective evaluation of health status was assessed using the question what is your current general health compared to last year how is your current health and how is your health status compared with that of others of the same age responses were provided on a 5point likert scale and the score of each item was summed to obtain the total seh score with a higher score indicating better seh the physical health of the participants was measured using the international physical activity questionnaire short form the ipaq measures daily physical activities including walking moderate and vigorousintensity activities and sitting in the past 7 days and their duration and frequency the weekly total energy expenditure was calculated as the sum of weekly energy expenditure for each type of activity the total met is the sum of 33 × walking 40 × moderate score and 80 × vigorous score frailty was assessed using the korean frailty index and consisted of eight items hospital admission selfassessment of health status polypharmacy weight loss depressive mood incontinence time up and go test and visual or auditory problems using a yesno response format the total scores range from 0 to 8 with scores of 02 34 and ≥ 5 indicating robust prefrailty and frailty respectively nutritional status was measured using the mini nutritional assessment which comprises six items food intake decline in the past 3 months weight loss in the past 3 months mobility psychological stress or acute disease in the past 3 months neuropsychological problems and body mass index the mna ® sf was strongly correlated with the original total mna score with a sensitivity of 979 specificity of 100 and diagnostic accuracy of 987 the total score ranges from 0 to 14 points nutritional status is categorized as normal risk of malnutrition and malnourished loneliness was measured using the 20item ucla loneliness scale on a fourpoint likert scale scores ranged from 20 to 80 with higher scores indicating a higher level of loneliness depression was measured using the korean version of the short form geriatric depression scale developed by sheikh and yesavage which contains 15 items ten items indicated the presence of depression when answered positively whereas the remaining five items indicated the presence of depression when answered negatively the total score ranged from 0 to 15 and was categorized as follows 05 normal 69 mild depression and 1015 severe depression suicidal thoughts and suicide attempts were measured using two questions participants were asked whether they had seriously thought about committing suicide and could answer a 0 to 10 point visual analog scale a higher vas score for suicidal thoughts indicated more thoughts about suicide suicide attempts were measured by the question during the past 12 months how many times did you actually attempt suicide social health of the participants was assessed using the enhancing recovery in coronary heart disease social support instrument the korean version consists of six items based on perceived emotional instrumental informational and appraisal support the scale had a total score ranging from 6 to 12 higher scores indicated greater social support healthrelated quality of life hrqol was measured using euroqol 5 dimensions it is a standardized instrument developed by the euroqol group which can be used for a range of health conditions the eq5d consists of five dimensions mobility selfcare usual activities paindiscomfort and anxietydepression the possible responses for each dimension included none slight moderate severe or extreme problems and the responses were converted to quality of life scores using korean value sets the eq5d index score has been suggested using the time tradeoff method and the range is from 1 meaning the worst health to 1 meaning perfect health the higher the index the higher the subjects healthrelated quality of life eqvas evaluates imaginable health status that ranges from 0 to 100 data collection all 69 assistants received preliminary training on the purpose and outline of the study and survey method before undergoing facetoface surveys a gerontological nurse practitioner was always present as participants completed the questionnaires to clarify any doubts they had the participants were evaluated at followup with a baseline assessment using the same measurement they took approximately 40 min to complete the questionnaires and measurements and were given daily necessities as a small token of appreciation afterward data analysis using spss version 23 data on the longitudinal participants characteristics were analyzed through changes in descriptive analyses using the wilcoxon signed rank test and chisquare test generalized estimating equations were used to assess changes in health status and the interaction effect of time and gender then we performed stepwise multiple logistic regression analysis to identify factors related to hrqol before running the regression analyses the independent variables were tested for multicollinearity using the tolerance value and variance inflation factor if the tolerance value is 01 and the vif value is ≥10 multicollinearity is problematic all comparisons were twotailed and statistical significance was set at a pvalue 005 results general characteristics the general characteristics of the 789 participants at baseline and followup are shown in table 1 there were significant differences in participants total monthly income and cost of living between baseline and followup the findings revealed more time and gender specificity in health status the physical health mental health social health and quality of life of older adults living alone showed statistically significant differences in time and gender time differences were observed in seh ipaq scores frailty nutritional status and depression gender differences were observed in seh ipaq frailty loneliness depression and social support however the interaction between time and gender was only observed in the ipaq score the interaction effect of time and gender on eq5d5l mobility usual activity and pain and discomfort were significant eqvas decreased after 1 year but was not statistically significant figure 1 indicates a decrease in eq5d5l and an increase in subcategory problems by time and gender mobility selfcare usual activity pain and discomfort and anxiety and depression problems influencing factors in hrqol the results of the multiple regression analysis showed that the factors affecting the baseline hrqol were age gender seh frailty and depression when combined these factors showed a 378 variability in baseline hrqol conversely after 1 year participants hrqol was significantly related to their gender cost of living seh frailty depression loneliness suicidal thoughts social attempts and social support the combination of these variables showed 439 variability in followup hrqol the tolerance value which is a collinear statistic was 06140902 for the baseline model and 04330920 for the followup model all of them were ≥ 01 the vif was 11081628 in the baseline model and 10872309 in the followup model and all were below 10 thus multicollinearity was excluded discussion this study examined the changes in the health status and hrqol of south korean older adults and changes in the factors affecting hrqol to establish basic data for the development of health services that can improve the quality of life of older adults living alone most research variables of the general characteristics of older adults living alone were the same except for economic status which changed statistically income increased from us 50515 to us 54621 an increase of approximately 813 and the cost of living increased 1 year after baseline these results are related to the policies of the korean ministry of health and welfare thus the sum of basic living benefits and oldage pensions for singleperson households increased by 805 in 2019 from 2018 furthermore the cost of living was found to be an associated variable for hrqol therefore this suggests that the government should continue to take into account the inflation rate and make efforts to guarantee a minimum cost of living for older adults living alone we also found that the mna ® sf score significantly decreased over time the nutritional status of older adults is related to not only the digestive function but also the sensory function it is also related to economic status and worsens as aging progresses interestingly we found an interaction effect between differences in time and gender differences in hrqol among older adults in the present study the eq5d5l of older adults living alone decreased over the course of 1 year and the change in women was greater than that of men moreover this interaction between time and gender was found in mobility usual activity and paindiscomfort these results are consistent with reports of a lower quality of life with increasing age for women than for men moreover reducing and eliminating gender inequality is crucial for women and their ability to meet basic needs and improve their quality of life therefore it is necessary to maintain quality of life by preventing the sudden deterioration of womens health regarding the factors influencing hrqol in this study seh depressive symptoms gender and frailty were significantly associated with both baseline and 1year followup this finding is in line with the results of previous studies therefore controlling depression and frailty by gender could lead to good hrqol the suicide rate of older adult korean individuals in 2019 was 466 per 100000 deaths a decrease of 2 compared with that noted in the previous year however korea still ranks first among the member countries of the organization for economic cooperation and development in terms of gender the suicide rate for men and women decreased by 67 and 13 respectively the same results figure 1 healthrelated quality of life by time and gender showed that the suicide rate for older adults living alone decreased after 1 year and in men but increased in women moreover the primary reason for older korean adults reporting suicide attempts was physical problems followed by mental and psychiatric problems and then financial concerns a previous study on older adults with executive dysfunction showed that age ≥ 75 years living alone and low socioeconomic status were associated with suicidal ideation or attempts in this context suicidal thoughts can lead to a lower quality of life in this study frailty depression and cost of living were found to affect the quality of life along with suicide therefore there is a need to improve the quality of life and suicide prevention through physical mental and economic interventions the who emphasizes community care and agingfriendly environments strengthening social support is emerging as an important policy because it prevents social weakness and improves the quality of life of older adults in a previous study integrated social networks were associated with higher physical function and nutritional status at an 8month followup moreover webbased message consumption had a more significant effect on reducing depressive symptoms in older adults over time than offline support networks thus there is a need to develop social networks and support systems for older adults living alone using information and communications technology to easily and frequently meet integrate and systematically approach physical mental and economic support limitations this study is the first attempt at a largescale longitudinal study investigating the changes in health status and hrqol of older adults living alone in an urban area of south korea this study has the following several limitations first the followup period was relatively short even if we attempted to conduct a cohort study to improve the validity of the results it is necessary to conduct more longterm observational studies of cohorts specifically the health status and hrqol of older adults living alone before the covid19 pandemic should be investigated longitudinal research is necessary to investigate the factors affecting changes in health status and quality of life of older adults in the current situation second although efforts were made to approach them as comprehensively as possible other potential confounding variables that might also affect the hrqol of older adults living alone were not included in this study and should be included in future studies thirdly due to the convenience sampling method used in the study the sample of this study was drawn from only one community in south korea this affected the representativeness of the questionnaire respondents and limited the generalisability of the conclusions finally in order to examine the relationship between changes in health status and hrqol only participants who were followed up were included in this study in order to reduce the dropout rate in the future as those who dropped out were often the oldestold measures such as doortodoor surveys to follow up older adults should be considered conclusion we found changes in the health status and hrqol of older adults living alone there were differences in time and gender in physical health mental health and cognitive function furthermore there were interaction effects between gender time physical activity and hrqol we also found evidence that hrqol is associated with physical health mental health and social support to improve the quality of life of older adults living alone it is necessary to provide economic support to prevent depression loneliness and suicidal thoughts through psychological support and strengthen social support further research should establish a cohort in which the social frailty group ie older adults living alone is investigated through continuous longitudinal observation these findings have implications for public health efforts to provide genderbased community services and social and economic support and prevent frailty depression and suicide which increase hrqol in older adults living alone data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving humans were approved by the institutional review board of seoul national university hospital the studies were conducted in accordance with the local legislation and institutional requirements the participants provided their written informed consent to participate in this study funding the author declare financial support was received for the research authorship andor publication of this article this research was supported by a grant from the korea health technology r d project through the korea health industry development institute funded by the ministry of health and welfare republic of korea publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at full supplementarymaterial

background the percentage of older adults living alone is rapidly increasing improving the health status and healthrelated quality of life hrqol in this group is becoming a more significant public health issue this study aimed to examine the changes in the hrqol of older south korean adults living alone and identify the factors that affect their hrqol methods a longitudinal study design was followed data were collected at baseline and 1year followup participants consisting of 789 older adults living alone in s city aged 65 years completed a cohort survey regarding health status and hrqol from august 2018 to august 2019 trained interviewers conducted facetoface interviews with the participants using a validated questionnaire physical health mental health social health and hrqol generalized estimating equations were used to assess the change in health status and the interaction effect of time and gender then a stepwise multiple logistic regression analysis was performed to identify factors related to hrqol results time differences were observed in the subjective evaluation of health status seh ipaq scores frailty nutritional status and depression gender differences were observed in the seh ipaq frailty loneliness depression and social support the interaction between time and gender was observed in the ipaq and hrqol at baseline seh depressive symptoms gender frailty and age were associated with hrqol after one year hrqol was associated with seh frailty depressive symptoms cost of living suicidal thoughts gender social support loneliness and suicide attemptsour results highlight that hrqol is associated with physical health mental health and social support future detailed studies are needed to determine whether governments and communities can prevent depression loneliness and suicidal thoughts through psychological support

introduction language is a system of sounds words and patterns humans use to communicate their thoughts and feelings it is the source of thought expression through speech sounds it is the most powerful convenient and permanent form of communication at both the individual and social levels language serves as a symbol of identity according to dr shahid siddique language has a significant role in a nations social political cultural and economic institutions the importance of dominant languages is becoming increasingly obvious in the aftermath of globalization as native languages face the prospect of extinction among their own speakers language may be considered a bridge of communication on one level and a representation of identity and nationality on another level pakistan is a multicultural multiethnic and multilingual country and it has been facing many challenges of multilingualism since its independence in 1947 each province of pakistan has its own culture including its beliefs traditions rituals dresses food and language there is a diversity of cultures in pakistan while there is also a diversity of languages therefore it is known as a linguistically diverse region as the majority use more than one language there are almost 77 languages spoken in pakistan among which six are major and others are minor languages spoken by a specific group of people urdu is the national language of pakistan a lingua franca that connects the people of the whole country and only 8 percent of the population acquires it as their mother tongue another major and official language in pakistan is english which dominated all other languages after britains rule in the subcontinent currently it is the most powerful language and all other languages are associated with people of the lower and middle classes in pakistan english is still regarded as the language of the upper classes and is used in both formal and informal situations due to its high status the english language is becoming dominant and small languages are being suppressed other languages are losing their identity which is why the powerful are ruling and have command of the english language language is fundamental in the formation of national identities however this position on language has undesirable consequences when one language is used to define national or provincial identity it can lead to the development of laws that oppress other ethnic groups or linguistic minorities this is certainly the situation in pakistan where 582 urdu and english enjoy official legitimacy while suppressing the other languages similar circumstances apply to provincial languages which have the potential to repress other linguistic minorities in those regions as a result of the abovepresented picture of pakistan a number of challenges are faced due to multilingualism such as facing barriers while communicating learning problems in a multilingual classroom getting different treatment on the basis of language impact on their personal and social identities different ethnic groups rioting political conflicts among groups the dread terror of dominance and prejudice among individuals a higher risk of social conflicts having particular stereotypes and injustices towards certain languages multilingualism within a country result in poor communication between members of different language communities and between those communities and the government it can lead not only to mistrust and political tension but also to poor levels of literacy and problems in the judiciary when different languages may be used and transcripts are required in order for a case to be heard at all language barriers impede international communication in general and individuals in particular by rendering them unable to speak with and correspond with whomever they wish or read the periodicals and books they want to read bilingualism enables people to participate fully and directly in world culture and universal dialogue monolingualism leaves the individual with a more parochial and fearful worldview the media contribute to the experience of linguistic diversity and thus aid in the spread of multilingual practicesthat is how we use different languages and transition from one to the other media is playing an active role in the twentyfirst century there are various types of media such as print media electronic media and social media todays media environment is inevitably multilingual the media is a site of multilingual practices and a source of information various education commissions plans and language policies have been developed to achieve multilingual competence but the goals have yet to be met the governments policy in pakistan is different from the realities on the ground in 2009 the government switched the teaching of sciences and mathematics from urdu to english beginning in grade 4 according to article 251 of the 1973 constitution of pakistan urdu should be used for official purposes the supreme court of pakistan ordered the federal and provincial governments to completely implement it on september 8 2015 but they failed to implement it the education policy in pakistan is promoting only english and urdu at the macro level while at the micro level bilingualism and multilingualism are the realities coming out of institutes english is a colonial language and is considered a language of power this is becoming a hurdle in the development of this language in pakistan and the development of pakistan in the circle of developed countries this paper highlights such aspects that need to be changed by investigating the issues of multilingualism in pakistan the study hopes to achieve the following research objectives the first goal is to investigate the distinctive challenges that restrict english language growth and competency in pakistan the second goal is investigating and analyzing ideas and solutions that successfully solve the multilingualism concerns the findings will add to the existing repository of information and serve as a significant resource for policy makers instructors and language specialists in developing successful policies and interventions to promote multilingualism and language development across the country research questions this research paper is guided by the following research questions 1 how can multilingualism be challenging for the development of the english language in pakistan 2 how can different kinds of strategies and solutions be employed to overcome these challenges literature review the notion of multilingualism is defined as the use of two or more distinct and independent languages by any society as its primary means of communication multilingual refers to a person who speaks more than two languages pakistan has been dealing with the problem of multilingualism since its inception in 1947 it is a multilingual country with 77 different spoken languages each province has its own language and culture because it is associated with a distinct ethnic community english along with urdu is regarded as the language of administration the urdu language is most commonly used for communication and as a lingua franca among many ethnic groups it promotes national solidarity among pakistanis a role it previously played between muslims in the subcontinent before separation in 1947 nevertheless english is still the preferred language of the pakistani aristocratic class and is used in both professional and social settings due to its prestigious position as the language of education law administration science and technology it has highly integrated itself into pakistani culture and is seen as very valuable by the vast majority of the population whereas other languages are excluded from the official and power structures of the federal government as well as from provincial power structures such as the punjabi language in punjab however other significant indigenous languages spoken in pakistan are shown below in the chart figure 1 2017 census punjabi is used in the province of punjab as the mother tongue of many of punjabs people pashto is used in khyber pakhtunkhwa sindhi in sindh and balochi in baluchistan as the mother tongue these languages are sacrificed in pakistan and more privilege is given to urdu and the english language english language courses are compulsory at every level of education but teaching methodologies are not clearly defined and teachers are not provided with instructions regarding teaching methodologies which is the reason for the low percentage of communicative competence in english social and cultural approaches to language studies have shown a nuanced picture of language use and instruction learning a language is a process of becoming familiar with a communitys social and cultural norms of which language or linguistic performance is a crucial component additionally learning a language is an investment in developing a sense of national identity and effect the many identities of learners access to language learning is a significant issue for learners especially those learning a second language according to related studies people who dont know any languages well are likely to fall into the trap of speaking only the language that is spoken in their area which eventually lowers their chances of getting excellent employment and rising in society for instance verbal interactions at the local national and international levels in many nations including pakistan currently favors english over other languages the english language has turned into a commodity for speakers of other languages despite its status as an international language and possession of significant advantages planning for linguistic status in pakistan is founded on ideas of nationalism religion and development while nationalism and religion seemed to assist pakistans national goal of fostering unity among muslims of various ethnic identities development backed by english language proficiency became essential to pakistans progress in the worldwide community this idea of nationalism represented the nation as false if citizens could not assert sovereignty over a nationstate and had no right to national selfdetermination though nationalism is largely a political notion that offers a foundational definition to connect people with their place the country is more difficult to define than nationalism in multilingual countries like pakistan where this structure is governed by linguistic ideologies in administrative and educational contexts language is related to both the nation and nationalism but the structure of this intersection is exceedingly complex for instance the pakistani government is required by article 251 of the pakistani constitution to use urdu instead of english in official situations although in practice this has never been done according to capstick the british councils english language advisor in pakistan all groups will be valued provided people have access to education in their native tongue however pakistan is linguistically fragmented and the dominance of the two languages urdu and english has resulted in the marginalization of children who speak one of the numerous other languages that are spoken throughout the nation this issue has the potential to accelerate social and political conflict in the country a surveybased study of challenges of multilingualism in pakistan 586 research methodology a binary approach is utilized to examine the challenges of multilingualism in the development of the english language in pakistan the combination of quantitative and qualitative approaches gives a better understanding of research difficulties than either method alone as a result this study employed a combination of both quantitative and qualitative methods for the quantitative part of the study a sample of 30 students were chosen via purposive sampling a close ended questionnaire is given to these individuals in order to determine their present state of multilingual difficulty the acquired data is then statistically analyzed using spss version 29 the questionnaire consisted of fifteen statements intended to elicit information about the challenges of multilingualism in the development of the english language in pakistan the researchers selected the likert scale to get answers from respondents the selected likert scale consisted of the following categories strongly agree 1 agree 2 neutral 3 disagree 4 and strongly disagree 5 for qualitative analysis researchers employed content analysis as a tool to collect data from secondary resources for solutions to the challenges to examine prospective solutions content analysis is conducted on secondary sources such as past research publications and reports during the qualitative phase this mixedmethod approach gives a complete knowledge of the issues and significant insights for policymakers educators and language practitioners to build effective policies and treatments results and discussions findings pakistan as a multicultural and multilingual country faces many challenges regarding language use and development in this study different kinds of challenges are stated in the introduction and it elucidates how the education policy of pakistan is also becoming challenging to meet the future demands of regional languages as the researchers have used both qualitative and quantitative pieces of evidence for conducting the research on multilingualism primarily the data is collected from questionnaires and analyzed qualitatively to explain solutions to the challenges the questionnaire is designed to collect data regarding the challenges of multilingualism to determine the accuracy of the questionnaire the researchers employed the reliability test using spss 29 the reliability test produced a cronbachs alpha of799 which suggests that the result of the questionnaire was dependable the questionnaire asked a series of questions and the majority of respondents were between the ages of 22 and 40 participants results showed that multilingual people shouldnt have any trouble blending into a monolingual society or having trouble comprehending the context of conversations in various settings on th other hand they concur that multilingual people frequently make grammatical errors mix and switch between codes and create their own vocabularies because they are unable to learn the nuances of each language they also acknowledge that english and urdu are the two most widely spoken languages in pakistani multilingual societies and that political social and ethnic conflicts are raised by the use of multiple languages the following table shows the complete result of the questionnaire received by the respondents 588 language this right to language is being followed in pakistan 7 auto translator sometimes fails to convey the exact meaning of some words 37 53 10 0 0 8 teachers prefer to use the national language in a multilingual classroom 43 47 7 3 0 9 in multilingual classrooms there is no common first language 23 50 3 17 7 10 the political social and ethnic conflicts arise from the contact of multiple languages 30 40 10 20 0 11 the use of multiple languages influences the personal identities of individuals 43 40 17 0 0 12 the dominant language in the multilingual society creates a fear of influence among minority people 23 53 7 13 3 13 people tend to judge others on the merits of their language output 43 33 17 7 0 14 multilingualism manipulate a particular variety of a language within a particular context 17 47 27 10 0 15 only urdu and english are dominating while suppressing the regional languages 43 33 10 13 0 the results that are explained in the above table have been shown in the form of a graph responses showed that 27 of participants strongly agreed 43 agreed 12 were neutral 15 disagreed and 2 strongly disagreed with the statements in the questionnaire hence most respondents agree with the statements raised in the questionnaire regarding the challenges of multilingualism which show that the majority in pakistan is facing these challenges the importance of the english language is acknowledged by people and it is an international language that connects people across the globe and helps in the development of a country it is the language of trade for people who do business all over the world the language policy of pakistan promotes the english and urdu languages only the majority of pakistanis are facing these challenges of multilingualism only a few percent of the population understand the need for the english language nowadays in order to cope with these difficulties we must adopt new methodologies and strategies to meet the challenges of the development of english in a multilingual society discussion there are two aspects that will be discussed in the following subsections the strategies and the solutions in response to the current situation strategies in the national education policy the government acknowledged the symbolic value of english switching the a surveybased study of challenges of multilingualism in pakistan 590 teaching of sciences and mathematics from urdu to english beginning in grade 4 according to article 251 of the 1973 constitution of pakistan urdu should be utilized for official purposes following a 15year transition period from the date the constitution was signed since article 251 was passed by the national assembly in 1973 but never implemented the supreme court of pakistan ordered the federal and provincial governments to completely implement it on september 8 2015 the supreme court judgement has created an urgent situation in which it is critical to comprehend the linguistic ideologies that shape policymakers and educators in this intricate and nuanced environment solutions rahman suggests that in order to gain power while maintaining our linguistic abilities and sense of pride we need to add other languages to our repertoire the state and our educational system should promote the idea of linguistic rights local languages should no longer be discriminated against additionally people should be encouraged to tolerate other cultures and religions by raising awareness according to the european commission learning other languages offers so many advantages that the media can inform people about the advantages of learning an english language authorities can support the media in producing intriguing films series and documentaries about language awareness radio and television are also able to create instructive languages programmed alongside native tongues additionally subtitling films and news in english can have a significant impact on its development in this way the media can play a significant role in providing solutions to overcome these challenges moreover a lack of knowledge of another language can feel embarrassing or create misunderstandings in communication the worstcase scenario is that these errors could confuse or even offend the individuals were trying to communicate with which could lead to misinterpretations and cause conflicts among individuals however by educating people about this issue and the shared roots it has with their native tongues this makes them feel closer and promotes friendly relationships however decisions about language policies in a multicultural society like pakistan require deliberate planning for better implementation and should be guided by local conditions and requirements that are essential for successful policy implementation conclusion and suggestion conclusion this paper asserts that pakistan is a multilingual country due to the diversity of cultures that exist in the country with six major and many minor languages pakistanis face numerous challenges associated with multilingualism as the english language enjoys prestigious status in pakistan due to its colonial heritage and is the language of power effectively terminating all other minor languages and posing a barrier to the development of the english language in pakistan the current education policy of pakistan promotes english and urdu while subjugating all other minor languages such as punjabi pushto sindhi balochi and saraiki this paper elucidates different kinds of challenges and how the education policy is playing a vital role in the development of english urdu and other languages suggestion the researchers concluded with a recommendation that there is a need to make changes in the overall language policies of pakistan that should promote all languages equally while protecting the languages cultures and identities of pakistani people also minor languages are on the verge of extinction however by encouraging additive multilingualism pakistani languages will develop and endure as cultural treasures rather than cultural liabilities it is also suggested that future researchers undertake a longitudinal study to investigate the language development and experiences of multilingual persons in pakistan this type of research would be useful in understanding the longterm ramifications of multilingualism language change the evolution of language policy as well as the impact of language education policies furthermore researchers might perform a comparative examination of multilingualism in various areas of pakistan to investigate regional differences in language problems language attitudes language policies and their consequences on language practices and development researchers might identify distinct issues and dynamics peculiar to each location by comparing multilingualism across varied regions such as urban and rural areas or different provinces 592 these study ideas aim to expand understanding of multilingualism in pakistan by focusing on specific areas of language problems they can help create contextually relevant policies and provide the groundwork for future interventions to promote successful language practices and development

this paper aims to investigate how people face different challenges in a multilingual and multicultural society especially in pakistan the english enjoys official language status while urdu is the national language in pakistan minority languages on the other hand are a sign of stigma and destitution and most speakers of minority languages face discrimination in this paper a binary approach of qualitative and quantitative is used to explore multilingualism in pakistan in order to understand how pakistans language policy favors some languages over others and what impact that has appeared on politics society education and the economy a closedended questionnaire was given to 30 participants as part of the quantitative data gathering process utilizing the purposive sampling technique in the qualitative phase researchers used content analysis as a strategy to gather information from secondary sources in search of strategies and solutions to the challenges it also briefly examines the effects of globalization on pakistani languages the findings of the study revealed that there is a need to use such strategies that help overcome these challenges and help in the development of english as an international language future researchers can undertake a longitudinal study to investigate the language development and experiences of multilingual persons in pakistan and they can perform a comparative examination of multilingualism in various regions of pakistan

introduction harm reduction programs are evidencebased interventions which reduce both individual and societal harms of drug use and change risk environments 1 2 3 supervised injecting facilities and drug consumption rooms are harm reduction programs which provide space for safer drug administration in hygienic settings under the supervision of qualified staff 4 and are increasing in number worldwide 5 in 2016 92 sifsdcrs operated across 11 countries with the majority in germany the netherlands and switzerland several in spain denmark norway and france and until recently one each in australia canada and luxembourg 5 a trial sifdcr opened in melbourne australia in july 2018 5 and the canadian ministry of health has thus far approved 33 new supervised consumption services between 2016 and 2018 with further applications being assessed 5 the opening of sifs in portugal is scheduled for 201819 and is under discussion in ireland scotland and the us 5 sif clients have been described as regular injectors who are when they first attend the service at a higher risk of infectious diseases illegal sources of income incarceration unsafe injecting practices and unstable accommodation than infrequentor nonattenders 6 7 8 accordingly the aims and activities of sifs commonly span beyond safer drug administration and include referrals into drug treatment and health and social services 9 10 11 12 unitings sydney medically supervised injecting centre is the first and longestrunning supervised injecting facility in the southern hemisphere and over 16000 clients have registered with the service since 2001 sydney sif clients manifest high levels of marginalization and unstable housing 13 overall there are indications that the population of people who inject drugs is aging in australia 1415 and elsewhere 16 while risky injecting practices decrease with age 1718 health and social issues in aging populations of pwid tend to aggregate 161920 furthermore the marginalization of pwid impacts on the intent to seek treatment as well as treatment retention 16 this means that identifying sif clients needs and avenues for support is becoming increasingly important the sydney sif like other sifs and drug consumption rooms operates on harm reduction principles and meets clients where they are at the sif does not impose any mandatory health and social interventions on clients beyond the opportunity to use drugs in a safer and more hygienic manner referrals to health and social services including drug treatment at the sydney sif are similar to other lowthreshold programs in that they are opportunistic require the identification of clients needs and can benefit from trusting relationships between staff and clients research has indicated that the clients who attend the sydney sif more frequently are more likely to accept a referral to health and social services 1113 but these investigations have been limited in scope and have not directly addressed the changes if any in clients needs since their initial visit in this study we aimed to assess the current health and social needs of sydney sif clients transitions between lowerand higherrisk health and social indicators since the initial visit and the determinants of seeking support materials and methods the sydney sif clinical model has been described previously 21 briefly clients enter the reception area and must register the first time they use the service clients do not provide identification but a unique identifier is assigned to them at all subsequent visits clients declare their unique identifier and the drug they intend to inject and are assessed against admission criteria clients then proceed to stage 2 where they inject substances that they procured offsite under medical supervision in booths all injecting equipment is provided following injection clients move to the aftercare area and continue to be monitored by clinical staff until they leave the premises the service operates seven days per week and is open from 0930 to 2130 on weekdays and from 0930 to 1730 on weekends frontline staff are comprised of registered nurses and health education officers the detailed health and social information collected from clients at registration during their initial visit is not routinely updated a 42item questionnaire to update that information was developed which was based on the questions asked at registration the intervieweradministered questionnaire assessed a range of indicators including housing status employment and source of income physical and mental health incarceration history drug use in the last four weeks overdose history engagement in drug treatment and health service utilization of 15 local services spanning primary healthcare social support mental health drug treatment pwid peer organizations hospital emergency departments with an option of other in the last 12 months individuals who reported an issue in relation to any of the indicators assessed were asked if they would like support participants were also asked what was the most important issue for them at the moment and whether they would like to talk to one of the staff about it the questionnaire was reviewed by the sydney sif consumer action group a peerbased special interest group which regularly provides important feedback on projectrelated work being undertaken at the sif members reviewed the interview questionnaires and schedule and provided feedback on the language appropriateness and topic areas and reviewed the study findings clients in stage 3 were approached by a sif staff member who informed them about the study and determined eligibility people were eligible to participate if they had attended the service during the data collection period had attended the service on at least one other day and had not already participated participation was voluntary the questionnaire was administered by a sif staff member in a private clinic room interviews took approximately 20 min to complete answers were confidential in line with established practice participants were remunerated au 20 interviews were conducted across all opening hours and on 19 days during the data collection period all individuals gave their informed consent for inclusion before they participated in the study clients who were unable to provide informed consent due to their level of intoxication were approached again later or on another day the study was conducted in accordance with the declaration of helsinki and the protocol was reviewed by the human research ethics committee of the south eastern sydney local health district there were three parts to the analysis firstly we compared aggregate health and social indicators reported at the time of the survey to the aggregate health and social indicators reported previously at initial visit using the ttest for the equality of means secondly we investigated individual transitions between lowerand higherrisk health and social indicators at initial visit and at the time of the survey for each health and social issue and service utilization item individuals were categorized into those who reported the issue only at initial visit only at the time of the survey at both timepoints and at neither timepoint the proportions of individuals in each category were reported finally we performed a factor analysis across all relevant variables from the survey and service records to identify the factors which were associated with individuals willingness to discuss with staff housing issues drug use and treatment and takehome naloxone variables from the factor analysis that yielded factor loadings of ≥025 were included in separate stepwise logistic regression models to identify the characteristics which were significantly associated with willingness to discuss each of the three issues with staff stata 14 was used for all analyses results sample the demographic drug use and service utilization characteristics of survey participants are shown in table 1 survey participants were mostly male aged 43 years on average and had been injecting drugs since age 19 years the drugs that the participants used most frequently at the sydney sif were heroin and methamphetamine seventeen percent of participants selfidentified as aboriginal andor torres strait islander participants had on average been clients of the service for nine years the mean number of visits since their initial visit was about 800 in the past 12 months participants had received an average of two referrals to health and social services we interviewed 36 of all clients who visited the sydney sif during the study period survey participants and nonparticipants were remarkably similar in characteristics there were no differences between participants and nonparticipants in terms of gender age aboriginality drug used most often and age at first injection however survey participants were longer and more frequent users of the service and were more likely to report a health issue at their initial visit than nonparticipants aggregate health and social indicators the aggregate health and social indicators among survey participants at initial visit and at the time of the survey are shown in table 2 unstable housing was common among survey participants at both timepoints however there were marked differences between timepoints in other health and social indicators a comparison showed that the proportion of participants unemployed on government income support and experiencing a physical or mental health issue was notably higher at the time of the survey than previously at initial visit the proportion of participants attending a nearby local community health service and engaging in drug treatment also increased between the two timepoints transitions between lowerand higherrisk health and social indicators individual transitions between lowerand higherrisk health and social indicators at initial visit and at the time of the survey are shown in figure 1 between initial visit and the time of the survey there were transitions in all health and social indicators the largest being in relation to health and housing issues for example up to onethird of participants had a health issue and up to onequarter of participants were in unstable housing at one timepoint only current issues and extent of support requested the most important current issue and the extent of support requested for that issue among survey participants is shown in figure 2 the most important current issues were housing family or social issues and drug treatment or reducing drug use however of participants who voiced an important current issue not all requested support for that issue in comparison there was less fluctuation in terms of employment and the receipt of government income support as substantial proportions of participants reported unemployment and were receiving government income support at both timepoints subsequently the proportion of participants transitioning between lowerand higherrisk indicators within those domains were smaller than for health and housing in terms of drug use more than half of participants reported injecting opioids at both timepoints while thirtyeight percent of individuals reported daily injecting at both timepoints up to onequarter of participants were daily drug injectors at one timepoint only about half of participants reported that for the first time since their initial visit to the sydney sif they had attended a nearby primary healthcare service which targeted services to more marginalized communities including pwid current issues and extent of support requested the most important current issue and the extent of support requested for that issue among survey participants is shown in figure 2 the most important current issues were housing family or social issues and drug treatment or reducing drug use however of participants who voiced an important current issue not all requested support for that issue eight percent of participants reported that they were not experiencing any major issue at the moment for each category there was no significant difference between the proportion of males and females indicating that they were experiencing the issue participants were also asked if they were interested to receive support for six key health and social issues that the sydney sif is wellpositioned to influence about twothirds of participants requested support in at least one of the six key areas overall the most common request for support related to takehome naloxone training just under half of participants who had not previously received training were interested in being trained the next most common request for support was for hepatitis c testing and treatment most participants had previously been tested for hepatitis c among the minority that had not been tested 18 were interested in testing and treatment support for mental health was the least requested despite the high selfreport of current mental health issues factors associated with willingness to discuss issues with staff the factors associated with willingness to discuss housing issues drug use and treatment and takehome naloxone training with staff are reported in table 4 individuals who expressed a willingness to talk to staff about housing were those who were currently in unstable accommodation 557 p 0009 and had expressed housing as being a main issue individuals who were willing to discuss drug use and treatment with staff were more likely to be predominantly heroin users and had expressed drug use and treatment as being their main issue and were less likely to be currently in treatment the two factors significantly associated with willingness to discuss takehome naloxone training were being of aboriginal andor torres strait islander origin and having experienced an overdose elsewhere other than at the sydney sif 1 selfreport 2 database records 3 housing 4 reducing drug use andor access to treatment 5 only included those who were not trained already note multivariate logistic regression models used with stepwise selection adjusted odds ratios supervised injecting facility likelihood ratio degrees of freedom discussion this study found that over time clients engagement with treatment and a local lowthreshold primary healthcare service increased a direct or indirect outcome of referrals they received at the sydney sif the health and social situation remained stable for a large proportion of clients and improved for others nevertheless over time the overall health and social situation among people who attended the sydney sif deteriorated highlighting the dynamic and transitional nature of clients needs over the course of their sif involvement this is perhaps not surprising given clients ongoing substance use which is a highly stigmatized and criminalized behavior and likely to impact on their health situation hamper employment opportunities and increase contact with police 22 the large increase over time in the number of people who were engaged in drug treatment challenges the misconception that sifs encourage drug use and do not do enough to link people into treatment 23 on the other hand if people who are engaged in treatment are still using the sif then is the treatment working critics of sifs often point to a false dichotomy between treatment and harm reduction 24 and believe both cannot exist simultaneously in reality sifs can do both 25 treatment does not have to be the primary goal and support is growing for targeted lowthreshold healthcare and treatment which offers services without attempting to control drug use 26 the risk of overdose increases with the length of time injecting 27 so it is unsurprising that more participants had experienced a drug overdose at the time of the survey than at their initial visit to the sif however the onsite immediate overdose management at the sif 2128 may well have contributed to individuals staying alive longer over their on average 20year injecting histories 5 while a proportion of people were open to discussing support options for managing their health and social issues a minority who voiced a current issue were uninterested in support at the time this is perhaps not surprising given clients primary purpose for presenting to the sif is to administer their drugs for some however this may be because the issue of concern is being addressed by other services it also highlights the inability of lowthreshold services to enforce health and social service referrals onto unwilling clients 22930 individuals more open to support were those who were homeless used heroin had experienced overdose and selfidentified need not surprisingly unstable accommodation and experience of overdose outside the sif were strongly associated with willingness to discuss housing issues and takehome naloxone training respectively it is unclear why people who are aboriginal or torres strait islander were more open to support but it suggests that this marginalized population are willing to engage and warrant attention research from different international settings has consistently shown that more marginalized people use sifs 5 despite different settings 5 frequent sif attendance increased the likelihood of referral to health and social services 1113 and engagement in drug treatment 3132 however we found that such indicators of sif service use were weaker determinants for requesting support than variables indicative of marginalization selfidentified needs and existing contact with relevant services the challenge of asking about and addressing peoples identified needs in lowthreshold settings is how to do so without inadvertently alienating people by making them feel they are problems to be solved a tenet of lowthreshold harm reduction services which service people who are highly marginalized is the ability to meet people where they are at this means providing a low barrier to accessing care and support it also means working with people in a flexible and consumerfocused way and accepting consumers as adequate and complete as they are and that they do not need to change anything to be accepted and valid individuals that can be hard to do but it is essential to effective engagement and gaining trust it is also an essential precondition to help people who are stigmatized to build confidence and motivation to make adaptive changes even changes that they themselves have identified as wanting the first step needs to be authentic humanistic engagement the risk of attempting to be proactive in providing support and problem solving before invitations to do so is that it inadvertently reinforces stigma and creates additional barriers to care for the consumer the nature of the support sought by clients may also challenge the service model canadian overdose prevention sites are a response to the opioid overdose crisis and focus on providing widespread safer injecting spaces they may lack the capacity to support health and social issues of clients 33 globally sifs also exist as standalone facilities within the immediate vicinity of supportive services for example the sydney sif is located near a lowthreshold primary healthcare service other examples include colocating sifs at detoxification services and healthcare facilities 35 the melbourne sif is now based within a community health service on a public housing estate however distance from support services is unlikely to be the main obstacle to care drug treatment and hospital services are often highthreshold programs which are constrained by abstinenceorientated approaches inflexibility and topdown organized programs which stigmatize people who use drugs 236 in australia consumers have expressed discontent even with methadone maintenance programs for their lack of clientcentered approaches 37 transitioning from a lowthreshold service might be a large step for sif clients and referral efforts from harm reduction programs can be hampered by the practices of highthreshold programs this issue warrants more careful consideration in terms of how referrals from sifs and other harm reduction services are managed and the way services which aim to address the needs of this population are developed there are several limitations to this study the surveyed sample represented about onethird of all clients who attended the sif during the study period participants were clients with longer histories of sif use a greater number of visits and accordingly more referrals which might have reduced the variability in the data and the significance of predictors in the logit models the resulting sample size was small when including all relevant variables and their respective missing values the potential for social desirability response bias may have influenced results similarly data may reflect the health and social situation of higherfunctioning sif clients as only people who attended the service were interviewed the overall deterioration in client situation as well as their increased access to services was of note a more rigorous study design could assess determinants of those individual trajectories also several questions in the survey were phrased differently than the questionnaire used at initial visit limiting the strength of some comparisons for example for some items there were differences in the assessment periods and response categories between questions asked at initial visit and questions asked at the time of the survey conclusions sif clients connect with health and social services over time and the referrals they receive onsite likely contribute to this many sif clients are open to health and social support at sifs even though they present primarily to administer drugs in a safer setting however the overall health and social situation of sif clients is likely to deteriorate over time albeit not uniformly clients who are most likely to respond to support are those with greatest need nevertheless engaging and referring clients from lowthreshold programs is just the first step in linking them to appropriate care more attention is needed to develop improved practices at the highthreshold programs to which they are referred if these opportunities are to be harnessed

health and social issues in aging populations of people who inject drugs pwid tend to aggregate despite risky injecting practices decreasing with age identifying needs and avenues of support is becoming increasingly important we described the health and social situation among clients of a longrunning supervised injecting facility sif in sydney australia an intervieweradministered survey n 182 assessed current housing status employment physical and mental health incarceration history drug use engagement in drug treatment health service utilization and willingness to accept support results were compared to the information provided at initial visit up to half of the participants transitioned between lowerand higherrisk health and social indicators over time willingness to accept support was greatest amongst those with higher selfperceived need support for mental health was a low priority despite the high selfreporting of mental health issues sif clients are open to support for health and social issues despite ongoing active drug use lowerthreshold services such as sifs are wellpositioned to recognize and respond to deteriorating health and social issues for pwid facilitating care and treatment remains a challenge when the services to which people are being referred are higherthreshold with a more rigid approach

introduction severe acute respiratory syndrome coronavirus2 the cause of covid19 is highly transmissible through close proximity with an infected person from early march through late april 2020 australian jurisdictions implemented restrictions in response to covid19 during initial shutdown periods people could leave their homes for essential shopping to provide care or seek medical treatment to exercise or to commute to workstudy if not possible from home and were advised to restrict sexual encounters to established intimate partners research in australia and elsewhere has documented impacts of covid19 restrictions on mental health in the general population including increased feelings of stress and isolation and producing or exacerbating mental health problems social connection and support are protective against declines in mental health during the pandemic while the covid19 pandemic presents mental health challenges for the general population physical distancing restrictions may have specific impacts on gay and bisexual men who typically have higher prevalence of mental illhealth than the general population restrictions associated with covid19 may prevent gbm from accessing critical sexualityaffirming supports peer support among gbm and engagement with gay community have been found to counter negative mental health effects increase healthseeking behaviors and assist men to find a sense of belonging crosssectional research has documented emerging concerns about the mental health of gbm due to covid19 with studies during the covid19 period finding that just under onethird of gbm experienced depression or anxiety that those who practiced physical distancing were more likely to feel anxious and another reporting that over half felt they needed help with a mental health problem a systematic review from the united kingdom found that mental health and wellbeing outcomes were poorer among lesbian gay bisexual and transgender people but the low data quality was noted researchers have called for specific monitoring of sexual minorities and mental health during the covid19 pandemic in the context of preexisting disproportionate burden of mental illhealth among gbm coupled with a higher likelihood of experiencing cosituated challenges such as stigma and discrimination mental health services need to be cognisant of the unique needs of this population during the pandemic our ongoing cohort of australian gbm provided an opportunity to explore the impact of covid19 on depression and anxiety in this population this analysis aimed to determine changes in symptoms of depression and anxiety after the initial implementation of covid19 physical distancing restrictions including trends between 2015 and 2020 and identify factors associated with increased symptoms of depression and anxiety after the initial implementation of covid19 physical distancing restrictions method participants and procedure the following lives undergoing change study is a national online prospective observational study of gbm in australia launched in 2014 the study protocol has been published men were eligible to participate in the study if they were ≥ 16 years of age identified as gay or bisexual or had sex with a man in the previous 12 months and lived in australia participants provided informed consent by selecting a checkbox on the online survey indicating they had read and understood the requirements of participating in the study no compensation was offered for participation ethical approval was provided by unsw sydney the study was promoted by online advertising on social media and gay sexual networking sitesapps participants completed online surveys at sixmonthly intervals in early april 2020 participants were invited to complete a survey round with new questions assessing the impact of covid19 men were included in this analysis if they had participated in a flux survey during 2019 and completed the depression and anxiety measures at least once and participated in the 2020 covid19 round and provided complete responses to the depression and anxiety measures measures depression was measured using the patient health questionnaire and anxiety was measured using the generalized anxiety disorder assessment both are wellestablished instruments and align closely with diagnostic criteria for major depressive disorder and generalized anxiety disorder respectively patients rated each symptom from 0 to 3 scale scores were calculated for each participant a score of 10 on each scale was considered the clinical cutoff for symptoms consistent with depression or anxiety and were termed moderatesevere depression or anxiety respectively following mcmillan et al a ≥ 5 point increase between 2019 and the 2020 covid19 round on the phq9 or gad7 was taken as a clinically significant and meaningful increase in symptoms of depression or anxiety respectively questionnaires included demographic items such as age country of birth and sexual identity selfreported hiv serostatus and testing histories and sexual behaviors with male partners a validated measure of sexual sensationseeking was included to measure the propensity to seek out novel or risky sex as was a reliable twoitem scale measuring gay social engagement participants reported their postcode of residence using a previously published method estimating the proportion of men identifying as gay in every australian postcode we classified a postcode as a gay suburb if the proportion of gayidentified men was in the 95th percentile or greater covid19related items were developed by the study team to measure changes in sexual behaviors social behaviors attitudes employment and experiences of covid19 since physical distancing measures were first implemented in australia statistical analysis analysis was conducted using stata version 142 trends among the included men were examined from 2015 to 2020 mean differences in scale scores were compared using pairedsamples ttests these focused on means from 2019 and 2020 but for sensitivity also between 2018 and 2020 factors associated with increased depression and anxiety were identified in bivariate analysis with ttests for continuous variables and chisquare tests for categorical variables in multivariate analysis factors independently associated with increased symptoms were identified using logistic regression we present adjusted odds ratios 95 confidence intervals and pvalues results the phq9 and gad7 were completed by 913 men in the 2020 covid19 survey and of these 664 also completed the measures in 2019 compared to the 664 included men the 249 men who did not complete them in 2019 were younger less likely to have a university qualification and had higher mean scores on the phq9 and the gad7 in 2020 they were not different in terms of other demographic indicators hiv status or mean gse scale scores included participants had a median age of 44 years and 724 were university educated onequarter lived in a gay postcode most were born in australia and had an angloceltic ethnicity most were hivnegative while 77 were hivpositive and 33 were untested or had unknown hiv status there was a statistically significant decrease in mean gse scores between 2019 and 2020 depression figure 1a shows mean phq9 scores over time from 2015 to 2020 among the 664 men included in the analysis in the five years before 2020 the average mean phq9 score was 561 the mean phq9 score was 511 in 2019 and 655 in the 2020 covid19 survey to account for the significant decrease between 2018 and 2019 we also examined the increase between 2018 and 2020 which was also statistically significant the proportion of participants with moderatesevere depression increased from 188 to 255 further details on the scale categories are presented in supplementary table s1 between 2019 and 2020 158 participants increased ≥ 5 points on the phq9 indicating reliably increased symptoms of depression within these 158 men mean phq9 increased from 249 in 2019 to 1165 in 2020 while 76 of these 158 participants had a phq9 of ≥ 10 in 2019 this increased to 557 in 2020 in bivariate analyses compared to the 506 men without increased depression those with increased depression were more likely to be living with housemates have been laid off temporarily or permanently from work be concerned about losing their job due to covid19 have found it very difficult to stop going out for entertainment have found it very difficult to stop kissinghugging friends and family have found it very difficult to not have sex with new partners have lost contact with people they cared about be younger and have had higher mean gse score in 2019 they were less likely to have received support from work colleagues among the 51 hivpositive men very few reported difficulties accessing their hiv medications and this was not associated with increased depression similarly in total only two hivpositive participants experienced changes in their viral load and this was also not associated with increased depression in multivariate logistic regression factors independently associated with increased depression were concern about losing their job having lost contact with people they cared about and a higher gse in 2019 anxiety between 2015 and 2019 mean gad7 scores averaged at 410 mean gad7 was 380 in 2019 and increased to 495 in 2020 again to account for the drop between 2018 and 2019 the increase between 2018 and 2020 was also statistically significant the proportion of participants with moderatesevere anxiety increased from 127 to 173 further details on the scale categories are presented in supplementary table s1 oneinfive participants increased ≥ 5 points on the gad7 indicating reliably increased symptoms of anxiety within these 137 men mean gad7 increased from 205 in 2019 to 1022 in 2020 while only 58 of these 137 participants had a gad7 of ≥ 10 in 2019 this increased to 416 in 2020 in bivariate analyses compared to those without increased anxiety those with increased anxiety were concerned about losing their job due to covid19 found it very difficult to stop kissinghugging friends and family found it very difficult to not have sex with new partners were concerned about contracting covid19 were concerned about transmitting covid19 to others were concerned about getting sick with covid19 were concerned about overwhelming the health system had lost contact with people they cared about and scored higher on sexual sensationseeking in 2019 among the 51 hivpositive men difficulty accessing hiv medication and change in viral load were not associated with increased anxiety in multivariate logistic regression factors independently associated with increased symptoms of anxiety were finding it very difficult to stop huggingkissing friends and family and concern about overwhelming the health system discussion our results showed an increase in both depression and anxiety among gbm coinciding with the covid19 pandemic and introduction of physical distancing restrictions in australia to our knowledge these are the first such longitudinal data among gbm internationally we found precovid19 levels of depression and anxiety were higher in our sample of gbm than in general population studies using the same measures general population studies in highincome countries have reported the prevalence of moderatetosevere depression at 30 108 and moderatetosevere anxiety at 69 106 by contrast studies using the same measures in gbm have reported prevalence of depression at 125 283 and of anxiety at 106 180 in australia a 2007 national survey found that homosexualbisexual participants had 32 times the prevalence of affective disorders and 22 times the prevalence of anxiety disorders compared to heterosexual participants from these already high baseline levels we observed a 28 relative increase in phq9 mean scores and a 30 relative increase in gad7 mean scores between 2019 and the 2020 covid19 survey in 2020 onequarter of participants screened positively for moderatesevere depression and 17 moderatesevere anxiety similar to levels found in crosssectional studies of the general australian population during covid19 nearly onequarter of participants had increased depression while onefifth had increased anxiety these changes were associated with a range of factors including concerns about job security and work reduction in social and sexual connection or opportunities and concerns related to acquiring or transmitting covid19 or impacts on the health system some studies examined mental health among gbm in the early covid19 pandemic in an online survey of lesbian gay and bisexual people in hong kong 315 of participants met the condition for clinical depression and 279 for anxiety while 347 reported reduced contact and connection with other gbm due to covid19 restrictions a global online survey of 2732 gbm across 103 countries conducted in aprilmay 2020 found that 35 screened positive for depression and 34 for anxiety these studies reported higher prevalence than found in our data but the participants were sampled from different countries with varying covid19 epidemics and human rights frameworks as crosssectional studies like these could not measure depression and anxiety preand postcovid19 restrictions it limits their ability to attribute mental health problems to covid19 or other factors in a large populationbased longitudinal study of the general population in the united kingdom clinically significant levels of mental distress rose from 189 in 201819 to 273 one month into the covid19 restrictions in the uk it was reported that the increase in mean scores on the general health questionnaire was greater than expected by the preexisting trend outside of our study similar longitudinal data do not appear to be available for gbm several factors relating to employment were associated with increased depressionanxiety losing employment due to covid19 was associated with depression while concern about losing employment was associated with both depression and anxiety this supports other research in the general population and with sexual minorities showing that employmentrelated impacts are an important mental health stressor during the pandemic concerns about covid19 itself such as being worried about contracting it transmitting it to others getting sick or overwhelming the health system were associated with increased anxiety but not depression in multivariate analysis concern about overwhelming the health system was one of only two factors independently associated with increased anxiety in both those with increased symptoms of anxiety and those without the factors relating to concern for others were of greater concern to participants than factors relating to concern for the self interestingly while some factors related to sexual practice were associated with increased depressionanxiety such as finding it very difficult to forego sex with new partners or sexual sensationseeking actual reductions in sex with casual partners or fuckbuddies during covid19 restrictions were not the mental health effects of covid19 restrictions thus appeared to be more related to desire and expectations about sex rather than actual changes in behavior relationship status was also not associated with increased depression or anxiety counter to some international research showing that being in a relationship is protective against depression on the other hand greater social engagement with other gay men prior to covid19 was strongly associated with increased depressive symptoms suggesting that men who socialized more with gay friends before covid19 struggled more with the restrictions than men who were less socially engaged alternatively it could be that protective aspects of spending time with other gay men were disrupted items relating to loneliness more generally were associated with increased symptoms of both depression and anxiety as was experiencing difficulties due to reducing physical contact with friends and family initial increases in depression and anxiety among gbm after physical distancing restrictions were introduced may represent a shortterm spike which may fall as people adjust or restrictions ease however other trends may also occur such as stabilization at a higher level or even further increases differential geographic impacts of covid19 are highly likely to be relevant in australia physical distancing restrictions are largely implemented at the state level while all jurisdictions had initial success in containing covid19 they had varying levels of success thereafter more populous states such as new south wales and victoria experienced stricter restrictions in particular residents of melbourne victoria were placed under one of the strictest lockdowns globally from july to october 2020 impacting the ability to make and maintain social and sexual connections and placing limitations on employment for many people we will examine these issues in a future analysis of an ongoing covid19related extension to the flux study whereby participants were invited to complete the phq9 and gad7 every four weeks some implications arose from our analysis generally the factors associated with increased anxiety and depression in our sample of gbm were ones that likely apply to all populations rather than being specific to gbm such as those related to employment or loss of social contact however although it appeared from our data that covid19 did not detrimentally affect gbm to a greater extent than the general population it is important to acknowledge that experiences of sexualityrelated stigma and discrimination may impact gbms access to appropriate mental health services previous research has indicated that gbm have struggled to access sexualityaffirming and culturally safe mental health support covid19 has highlighted why there is a critical need for generalist mental health support services to be culturally sensitive to diverse populations and where possible indicate to prospective clients that their services are gbmfriendly such services should consider telehealth approaches to avoid disruptions to mental health care our finding that higher gay malespecific social engagement prior to covid19 was associated with increased depression has suggested that there may be an important role for lesbian gay bisexual and transgender community organizations during periods of covid19 restrictions in providing online social support and community connection while a significant strength of our analysis was the capacity to compare the mental health of gbm during the first month of covid19 restrictions to previous mental health data in the same cohort the analysis has some limitations we used an online convenience sample and findings may not be representative of all gbm men in australia the sample was somewhat older than other typical samples of australian gbm was highly educated and comprised mostly australianborn men the covid19 survey instrument itself may not have included all pertinent variables related to mental health among gbm including quality of relationships and experiences of homophobia given that the flux study is primarily focused on hiv prevention sexual practices and drug use measures related to experiences of covid19 were not validated but due to the rapid onset of covid19 and the desire to implement rapid monitoring this was unavoidable and likely affects most early covid19 research studies although a longitudinal study we cannot be certain that covid19 caused changes in depression and anxiety especially given that the pandemic occurred immediately after some months of bushfires that could also have impacted mental health for some australians conclusion covid19 and the associated introduction of physical distancing restrictions in australia had a sudden and pronounced impact on the mental health of gbm with increases in both depression and anxiety observed ongoing monitoring is required to determine the longerterm impacts including to examine protective factors associated with resilience while most factors associated with increased depression and anxiety were relatively general and not specific to gbm given high baseline prevalence of mental health issues in this population it is critical to ensure gbm have access to appropriate and sensitive supports as well as evidencebased interventions both during and after the covid19 pandemic data availability not applicable code availability not applicable ethics approval this study was performed in line with the principles of the declaration of helsinki ethics approval was received from the human research ethics review committee of the university of new south wales informed consent all participants in the study gave informed consent 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 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we examined depression and anxiety prior to and during covid19 restrictions in australian gay and bisexual men gbm in an online cohort a covid19focused survey was conducted in april 2020 during 2019 and in april 2020 664 gbm completed the patient health questionnaire phq9 measuring depression and generalized anxiety disorder assessment gad7 measuring anxiety increased depression and anxiety were defined as a ≥ 5 point increase on the respective scales

background it is well known that a young age at the first experience of intercourse a poor condom use and an increase in the number of lifetime sexual partners favour the transmission of sexually transmitted diseases 1 with possible serious medical an social side effects with considerable consequences to the lives of the affected every year approximately 90 million new cases of genital chlamydia trachomatis infection are diagnosed worldwide 2 and this infecting pathogen is the most commonly responsible for std according to the world health organization 3 the most severe consequences of chlamydia affect women and although many of these infections remains asymptomatic 1 pelvic inflammatory disease occurs in 30 of the untreated women and approximately one third of these women will become infertile have ectopic pregnancies or develop chronic pelvic pain leading to an increased risk of cervical cancer and pneumonia of the newborn 2 chlamydia with a mean incidence rate of 467 cases per 100000 inhabitants in 2009 4 is the most common reportable sexually transmitted infection in norway and the two northernmost counties troms and finnmark with a population of 155061 and 73787 5 have had the highest chlamydia incidence rates in norway with 684 and 898 respectively 4 not enough 70 of reported chlamydia cases are found in people below 25 years of age 6 analyses of chlamydia test numbers in norway have also shown that the frequency of testing is low in the youngest age group which is at high risk of infection 7 promotion of safer sex practices through ict young people generally lack knowledge about sexually transmitted diseases and are more aware of the risks of unwanted pregnancy than their risk of acquiring a std 1 in view of the situation the information and communication technology could be a good way to achieve that youth become more aware of stds because norway has one of the highest internet penetration rates in the world 8 and these media are among the most powerful influences in the lives of young people 9 a norwegian survey performed in 2 nd quarter 2011 found that 100 of youth from 16 to 24 years old had been using internet in last 3 months 93 of them use internet every day or almost every day and 96 of activities on internet were related with social networks as facebook twitter etc 10 the use of ict related with sexually transmitted diseases has been studied during last recent years 1112 now we have a greater knowledge about the important role of internet on std knowledge and sex education for young people 1 and we can say that although the broad dissemination of personal computers smartphones internet access and social networking sites particularly in developed countries has created a new risk environment in which potentially stdinfected sex partners meet but also an intervention can occur for conducting promotion of safer sex 111314 a bibliographic review performed by swendeman and rothermanborus shows the efficacy of computerbased internetbased and mobile phone behavioural for std prevention and treatment support interventions 14 the authors found that ict can transform targeted routine and consumercontrolled sexually transmitted disease testing as well as the partner intervention 14 a more recent study with young people aged 15 to 24 from vancouver found that in general youth are particularly receptive to internetbased services 15 youth in this study suggested that online std risk assessment and testing as well as online counselling and education could enhance opportunities for lowthreshold service provision online services appealed to youths needs for convenience privacy as well as expedient access to testing andor counselling 15 however youth also appear to have relatively low tolerance for technologies that they perceive to be antiquated 15 interestingly evidence also suggests that certain health behaviours might spread through social ties of which online social networks are one example social network analysis is therefore regarded as a promising new field for monitoring the spread of stds and for development of new interventions for std control actually online social networking sites like facebook twitter myspace linkedin etc are being used for sexual health promotion 13 but despite their assumed potential benefits to disseminate online public health interventions there is a lack of knowledge regarding the effectiveness of those approaches 13 the use of social media in health promotion therefore be valued for their potential to engage with young audiences in fact a recent study concluded that more than 50 of the teenagers disclosed information about health risk behaviours in social media public profiles like myspace 16 consequently social networks appear to be fertile ground for gathering information about young peoples health behaviours and attitudes use of avatars in online health settings avatars also known as player or game characters are defined in computing terms as the graphical representation of a user but in psychological terms represents much more gives anonymity and freedom to users and at same time represents an opportunity for changing the behaviour of users 17 due to its potential to serve as models every day millions of users interact in realtime via avatars in online environments and these avatars or virtual self can even be programmed to behave independently of the physical self maximizing its utility as a persuasive agenthealth behaviour modelling 1819 related to the behaviour of users when defining the characteristics of the avatars while some authors have been analysing the importance of realism and interactivity of avatars in terms of behaviour and form on elearning environments 20 21 22 23 24 other researchers have studied the characteristics of avatars in relation to the context 25 and have found that in the dating and gaming treatments participants accentuated certain aspects of their avatar to reflect the tone and perceived expectations of the context for instance avatars in dating were made to look more attractive while avatars in gaming were made to look more intellectual 25 studies have shown that people infer their expected behaviours and attitudes from observing their avatars appearance this phenomenon is known as the proteus effect 17 these studies also analysed the expression of personality through avatars 26 and the relation between virtual and real world and have shown how the appearance of these avatars can lead to behavioural changes in users changing both how people interact with others in avatarbased online communities as well in subsequent facetoface interactions 1727 the main objective of this project is to achieve that north norwegian youngsters become more aware of stds through the use of popular technologies among young people methods to achieve the main objective a virtual clinic for sexually transmitted diseases will be developed the vcstd which will be hosted at will provide early guidance and reliable information sources concerning reproductive health delivered in a novel and innovative way to the younger population the vcstd consists of an avatar supported intervention in a serious gaming like and elearning environment which will bypass direct physical access to reliable medical information as well as allowing the youngsters to share that information in social media and thus helping the vcstd to be disseminated to more people the vcstd will be developed under the premise that information and communication technology may empower younger citizens to change their health related behaviour and lifestyle ict supported health related tasks such as seeking medical information could have a large effect in the reduction of costs and also allow reaching more people to provide behavioural intervention and support at less financial and personnel costs 14 the vcstd will also incorporate a feature to allow users to download and post content from the vcstd in their facebook profiles or other social media networks and a geolocation service that can be enableddisabled voluntarily by users and that may provide information for example where to find condoms or the location of the nearest health center the vcstd it is expected to start at the end of august 2012 users involvement youngsters from the two northernmost regions in norway troms and finnmark are expected to participate in this project but due to the vcstd project will be disseminated through facebook and users could share it in the social media participants from other parts of norway could be found or even norwegianspeakers fromin other countries upon registration which consists of creating an avatar the participant will receive a web unique link which enable himher to access the secured web and to enter data to access the vcstd the user has two possibilities 1 login by writing the username and password 2 clicking on the link and writing the password if the user needs to recover hisher avatar web link and or password the combination of giving the username and answering the secret question can be used then users could enter into the virtual clinic after choosing an avatar to represent them anonymously inside the clinic they will have access to a set of reproductive health resources such as videos articles audio quizzes and links each participant will be asked to interact more than one time although every created avatar from an ip belonging to one of the two northernmost regions will be analysed both the avatar and the provided data will be voluntarily entered by each participant and will be stored in their own profile the stored information will consist in different quizzes about hisher knowledge on std and how to prevent it other collected information will be the answers on a symptom check list techniques for recruitment gathering and managing data users will be recruited in two different channels both targeting north norwegian youngsters recruitment channel 1 will utilize social media for recruitment while recruitment channel 2 will be targeting traditional venues for public health recruitment recruitment to the vcstd will be aimed specifically at the two northernmost regions in norway this will include utilization of social medianetworks the trial will run one year from startup due to the nature of the project identifying individual participants will not be possible data analyses will therefore be conducted on publically available health data relevant to stds in troms and finnmark 1 absolute number of chlamydia tests 2 amount of emergency contraception medication sold and 3 number of abortions also experiences of usefulness will be explored through participants voluntary responses to a feedback form available in the vcstd the usage data of the system will be also used to evaluate the usability of the system users of the vcstd will be issued with an invitation to answer voluntarily one or more adhoc and anonymous questionnaires to assess how the site has affected their knowledge on sexual health std and specifically chlamydia and possibly their behaviour change andor motivation to test themselves for stds users could be asked also to answer voluntarily and anonymous short personality inventories like the sensationseeking scale 28 or the locus of control scale 29 a review of the project at the regional committee for medical and health research ethics is not applicable as patients are not involved in the research and all health data investigated are anonymous analysis the purpose of the study is descriptive so the results will be expressed in form of frequencies and percentages for each categorical variables and mean standard deviation and 95 confidence interval for continuous variables ttests anova correlation and chisquare analyses will be performed as well the opinions of users in the adhoc questionnaires about the site and how it has affected their knowledge will be analysed using qualitative techniques quantitative data analysis will be performed with the spss statistical package version 19 discussion this study will examine the usefulness of an online public health intervention avatars based and using computersmartphone mediated communication and social networking in prevention of sexually transmitted diseases and healthier sexual practices among northnorwegian youngsters considering that norway has one of the highest internet penetration rates in the world 8 and these media are among the most powerful influences in the lives of young people 9 a virtual clinic on std accessible through different technological platforms could represent a good way for educating young people on preventing stds especially chlamydia and the avatars of the vcstd could give anonymity and freedom to users and at same time could represent an opportunity for changing the sexual behaviour of youngsters 1730 taking into account that 96 of norwegians aged between 16 and 24 years old are using internet for social networking purposes 10 the social media could be a valuable resource for sexual health promotion to youngsters recruiting users and reach more people if the vcstd shown to be effective the intervention could prove to be an affordable and widely accessible intervention to decrease risky sexual practices among the younger population abbreviations aids acquired immunodeficiency syndrome ict information and communication technology std sexually transmitted disease vcstd virtual clinic for sexually transmitted diseases competing interest the authors declare that they have no competing interests

background sexually transmitted diseases stds especially the chlamydia trachomatis bacterial infection a common cause of infertility are highly prevalent in developed countries and a worrying problem in north norway where the incidence of chlamydia twice the norwegian average seventy percent of reported chlamydia cases are found in people below 25 years of age and although its spread could be controlled with proper prevention young people are more aware of the risks of unwanted pregnancy than their risk of acquiring a std information and communication technologies including the internet social media andor smartphones should be valued for sexual health promotion for their potential to engage young audiences and in these media avatars guarantee anonymity to users when handling sensitive information the main objective of this project is to achieve that north norwegian youngsters become more aware of stds through the use of popular technologies among young people methods a virtual clinic for sexually transmitted diseases vcstd will be developed the vcstd will provide early guidance and reliable information sources concerning reproductive health delivered in a novel and innovative way to the younger population the vcstd consists of an avatar supported intervention in a serious gaming and elearning environment which will bypass direct physical access in person to reliable medical information as well as allowing the youngsters to share that information in social media and thus helping the vcstd to be disseminated to more people data analyses will be conducted on publically available health data relevant to stds in troms and finnmark like the absolute number of chlamydia tests the amount of emergency contraception medication sold and the number of abortions also usage data of the system and experiences of usefulness will be explored through participants voluntary responses to a feedback form available in the vcstd discussion this study will examine the usefulness of an online public health intervention that aims to promote healthy sexual practices among northnorwegian youngsters if shown to be effective the intervention could prove to be an affordable and widely accessible intervention to decrease risky sexual practices in younger population

background sickness absence causes have different impact on the individuals chance of return to work 12 those with mental health conditions have a low rtw rate whereas those with eg infectious diseases have a relatively high rtw rate 3 compared to other health related diagnoses individuals on sick leave due to mental disorders have an increased number of sick leave spells and sick leave days 45 moreover many mental disorders are persistent and have high recurrence rates 6 are associated with increased risk of early retirement 7 and of receiving disability benefits 6 and unemployment benefits 5 the reason for the lower rtw rate in that group may not solely be attributed to the disorder itself it could also be explained by their lower rtw expectations 8 which are found to be a predictor for rtw 8 9 10 11 12 13 regardless of underlying conditions for sickness absence the rtw process after sickness absence is complex and evolving as it covers a series of events transitions and phases of employment status 1415 the criterion of rtw is not straightforward and there are different ways of defining a rtw outcome 16 17 18 research findings can vary with the way that rtw is defined and measured one way of defining rtw is to measure rtw status at a certain point in time after onset of sickness absence for example after 3 months 6 months or a year this is a convenient measure but one that may underestimate or overestimate the total effect of an employees work capacity because rtw rates vary over time other criteria for rtw that are used in the literature include time from injury to first rtw or the number of days lost from work after the injury in addition to these differences the measurement of the period until rtw may be based on actual days off work or a proxy measure such as compensation days until rtw 1619 the often adapted timetoevent approach does not cover the many possible states and transitions experienced by individuals on sick leave employment status transitions after sickness absence have recently been studied in the nordic countries by using multistate models 20 21 22 23 however sequence analysis has not previously been used to study transitions in sickness absence research this study will evaluate the rtw measures in a danish population on sick leave using both timetoevent analysis and sequence analysis with 51 weeks of followup the aim of this study was to investigate differences in rtw and employment trajectories in individuals on sick leave for mental health reasons and individuals with other healthrelated reasons for sick leave methods participants and design from september 2012 to march 2014 all new cases of sickness absence exceeding 4 weeks in the western part of denmark were registered they received a questionnaire about social characteristics rtw expectations and reasons for sickness absence the questionnaire was originally used for an rct study evaluating the effect of psychoeducation on rtw in individuals on sick leave 24 no difference in relative risk of rtw during the first 6 and 12 months after inclusion was found between the intervention group and the control group 25 the questionnaire was completed by 2788 individuals those who did not provide data on reason for sickness absence information on education employment and rtw expectations were excluded all participants were linked to the danish national labour market authoritys dream database 26 which provided information about economic compensation for unemployment sickness absence and other kinds of social transfer income the type of transfer payment in dream is recorded for each week if the person has received the benefit for one day or more termination of registration occurs following the first full week of not receiving any type of transfer payment if no transfer payment is registered for a specific week the person is considered to be selfsupporting and consequently as working in denmark a citizen in the workforce is entitled to sickness absence compensation and if the employee receives normal salary during the sick leave period the employer receives municipal reimbursement data from the dream database is increasingly applied in research and has been validated in research in individuals on sick leave 26 27 28 a total of 452 participants were not registered as being on sick leave in the dream database when the questionnaire was distributed and consequently they were excluded from the study it was done to avoid misclassification and that a difference in social benefits in the study could be attributed to a difference in social benefits at baseline thus the final study population consisted of 2036 individuals between 18 and 64 years of age data on registrations in the dream database was obtained from the week the questionnaire was sent and 51 weeks onwards outcome measures the outcome variable in this paper was employment status during the 51 weeks following the questionnaire and was recorded weekly in the timetoevent analysis the outcome was returntowork which was defined as the period between inclusion and the first period of 4 consecutive weeks without receiving any social benefits in the sequence analysis the outcome was extended to include five different categories for labour market participation and rtw 1 sickness absence 2 working 3 unemployment 4 temporary support and 5 permanent support working was defined as the weeks with no benefits and unemployment was defined as receiving unemployment benefits temporary support was defined as social benefits that are given temporarily aiming at promoting subsequent employment eg public education grant social assistance or rehabilitation benefit permanent support was defined as social benefits that are given on a permanent basis where regular employment is no longer possible eg early retirement public retirement pension and supported job exposure variables selfreported reason for sickness absence was the main exposure the participants stated in the questionnaire what they considered to be the reasons for their absence they could report several reasons but if they had reported anxiety depression other mental illness or stress and burnout they were categorised as having mental health reasons while the rest of the individuals were categorised as having other health reasons covariates information about education employment age gender and rtw expectations was retrieved from the questionnaire rtw expectations were estimated by the participants as the probability of not being on sick leave after 6 months the covariates were categorized as seen in table 2 ethical considerations participation was voluntary and the study has been registered and approved by the danish data protection agency the participants did not provide consent as the data were analysed anonymously statistical analysis initially a comparison of the individuals from the two exposure groups was made in relation to age gender education employment and rtw expectations by means of chi2 or ttests secondly the pseudo valueregression approach was used to examine differences in rtw between the two exposure groups by calculating relative risk and cumulative incidence proportions at the end of the 51 weeks of followup 2930 cip showed the percentages of individuals in each group who had returned to work the allocation of the rct study was adjusted for in all steps of the analysis 25 and thereafter different adjustment strategies were carried out based on variables that were chosen a priori 1 adjustment for gender and age 2 plus education and employment and 3 plus rtw expectations death emigration and receiving permanent support were considered as competing risk furthermore sequence analysis was performed which is a statistical study of successions of states or events a sequence is defined as an ordered list of elements and episodes expressed on a time axis 3132 in this study sequences showed a complete event history of labour market participation in each particular week from baseline to followup the relative proportion of each of the five employment status for every week was displayed in a status proportion plot 33 in the sequence analysis further 18 participants were excluded due to death or emigration thus in those analyses the study population consisted of 2018 participants in the sequence analysis the mean duration in weeks within a given state and the mean number of episodes of different status for the exposure groups were calculated differences between exposure groups were performed by using the syntax ttesti in stata by adding the n mean and sd for each group this syntax was used as sequence analysis was made in long format and thus regular tests were not possible to perform the distributions of the sequences were compared in the two exposure groups all individuals were divided into four groups according to their sequences 1 only sick leave 2 moving to continuous work 3 having at least one episode of work and 4 sick leave and social benefits the different distributions of sequences were tested in a chi2 test a volatility indicator was defined as the proportion of work and unemployment episodes in relation to total episodes episodes within work and unemployment reflected a positive status of rtw or readiness to rtw the volatility indicator indicated that the higher the value of this indicator the higher the quality of the transitions 34 an integration indicator was measured as an indicator of how quickly and to what extent the individuals reentered employment it was assessed as the sum of number of sequence positions where status was work which were weighted by their position within the sequence this indicated that the longer or more episodes in work the higher the quality of the integration process 34 moreover the sequences were grouped based on optimal matching algorithms and statistical cluster analysis to find and categorize observed sequences into a smaller number of clusters 3135 optimal matching was used to measure dissimilarities between sequences by applying the levenshtein distance measure which measured the number of operations that were needed to transform one sequence into another 31 similar sequences were grouped together using hierarchical cluster analysis with wards linkage 3435 on the basis of these results similar sequences were merged into eight clusters which were named based on employment status afterwards the distribution of the clusters across the exposure groups was tested by means of logistic regression the same adjustment strategies were used as in the pseudo value analysis point estimates were presented with 95 confidence intervals stataic 112 was used for all statistical analyses with the sqados to perform the sequence analyses results a total of 725 individuals reported mental health problems as reason for their sickness absence while 1311 reported other health reasons the most frequent diagnoses in the mental health group were stress and burnout depression and anxiety while in other health reasons musculoskeletal disorders chronicdiffuse pain and unclear reasons were most frequent the two exposure groups were significantly different in relation to all baseline characteristics individuals with mental health as reason for the sickness absence were more often women younger more than 3 years of tertiary education and had lower expectations of returning to work within the next 6 months furthermore they were to greater extent white collar workers and less often unskilled or skilled workers a total of 56 of those individuals who had reported mental health as reason for the sickness absence had returned to work at 51 weeks of followup which was significantly lower than 67 among those reported other health reasons during followup individuals with mental health reasons had a significantly higher risk of not having returned to work even after adjusting for gender age education and employment the difference was still present but somewhat attenuated when adjusting for rtw expectations the rr was the same in the two groups the status proportion plot illustrated the differences in employment status in the two exposure groups individuals with mental health reasons had significantly more weeks of sickness absence and temporary support throughout the year compared to individuals with other health reasons individuals with other health reasons had significantly more weeks of work compared to individuals with mental health reasons no difference in the duration of unemployment and permanent support was seen between the two groups the group with other health reasons had significantly more episodes of work whereas individuals with mental health reasons had more episodes of unemployment and temporary support no differences in the mean number of episodes in the five employment status or the mean number of different elements in the sequences were seen in the two exposure groups the range of episodes in the followup period was 123 in the group of mental health reasons and 126 in the group of other health reasons individuals with mental health reasons had a significantly lower volatility indicator and integration indicator compared to individuals with other health reasons during the followup period there were a total of 181 different sequences in the group with mental health reasons and 238 in the group with other health reasons the most frequent sequence in both groups was going from sickness absence to continuous work as it happened to 195 individuals from the group of mental health reason and 509 individuals from the group of other health reasons the second most frequent sequence in both groups was staying in sickness absence throughout the study period thus a total of 144 individuals with mental health reasons and 174 individuals with other health reasons were the eight clusters which were merged on the basis of similar sequences displayed aggregated shares of employment status three of the clusters displayed workoriented trajectories while two clusters indicated continuous sickness absence or relapse into sickness absence only one cluster showed a permanent withdrawal from the labour market while two clusters displayed general or partial temporary support individuals with mental health reasons had significantly higher odds for being in the sickness absence cluster and significantly lower odds for being in the fast rtw cluster after adjusting for gender age education and employment however when adjusting for rtw expectations the odds were somewhat attenuated and no longer significant moreover the individuals with mental health reasons had significantly higher odds for being in the relapse cluster although the number of observations was rather small also the individuals with mental health reasons had marginally lower odds for being in the slow rtw cluster however after adjusting for rtw expectations the or was close to 1 discussion main results individuals on sick leave due to mental health reasons spent more weeks on sickness absence and in temporary support and less weeks on work compared to individuals with other health reasons for sick leave moreover fewer of the individuals on sick leave due to mental health reasons had returned to work during the 51 weeks of followup compared to the individuals with other health reasons also the chance of having returned to work was lower for individuals with mental health reasons when adjusting for gender age education and employment status but after adjusting for rtw expectations the chance was the same in the two groups moreover individuals with mental health reasons had higher odds of being in the sickness absence cluster and a lower odds of being in the fast rtw cluster but the difference was attenuated after adjusting for rtw expectations rtw expectations the results show that rtw expectations can be considered a confounder in the effect of health reasons for rtw individuals with mental health reasons returned to work later than individuals with other health reasons but after adjusting for rtw expectations both exposure groups were found to return to work at the same time other studies have also found rtw expectations to be a predictor of rtw in both individuals on sick leave due to mental and physical disorders ie a positive rtw expectation predict a shorter time to rtw 8 9 10 11 12 13 it has been speculated that positive rtw expectations represent the selfefficacy of the employee ie the belief an individual has in hisher own capacity to perform a specific behaviour successfully in this case in relation to rtw 810 furthermore bad mental health and low rtw expectations could be influenced by the same problems ie problems meeting demands at work or at home social problems at work or other workrelated factors may have triggered both mental health problems and low rtwexpectations if the prospects of solving these problems seem low individuals with other health reasons had a higher level of rtw expectations than individuals with mental health reasons this has also been confirmed in a study by huijs et al 8 another possible explanation could be that the stigmatization of mental health problems in the workplace is high and therefore the employees might avoid their workplace and receive less support from their colleagues and supervisor making it seem less likely to return to work a third explanation of the lower rtw expectations among individuals with mental health reasons could be influenced by their psychological symptoms like hopelessness discourage and reduced selfconfidence these symptoms likely reduce the belief of rtw transitions in the rtw process the maximum number of episodes for one individual was 23 in the group of mental health reasons and 26 in the group of other health reasons this shows that the rtw process for individuals on sickness absence benefits may be long and complex 1536 which is in line with previous nordic studies using multistate models 20 21 22 23 it also emphasises the need to analyse rtw as a process 1415 and not only at a single point in time 3738 the advantage of this approach is that it provides a more complete picture of rtw and employment trajectories and therefore a more complete understanding of the impact of disability on the employees life and wellbeing 3639 during the last 10 years transitions of states have been used in the research of sickness absence by means of multistate models 20 21 22 23 pedersen et al showed the transitions for danish individuals on sick leave and with 4 year followup 22 they included the states work unemployment sickness absence and disability pension and identified predictors for each of the different transitions three norwegian studies have used multistate models to analyse the transitions of states 202123 lie et al applied three different states that low back pain patients could be in after an intervention recovery sick leave benefits or disability pension 20 while gran et al also included partial sick leave and work assessment allowance 23 oyeflaten strength and limitations the prospective design of the study and the record linkage of the cohort data with sickness absence data from dream added to the strengths of this study the study had complete followup of weekly employment status due to full coverage of registers of social benefits and the information is considered valid 26 moreover this study included sequence analysis to look at transitions besides the more traditional timetoevent outcome using the method has given an overview of the life course after the start of the sickness absence period sequence analysis is considered an exploratory method rather than a method for hypothesis testing which means that sequence analysis cannot answer the question of causality due to this sequence analysis is best used in combination with other methods and cannot replace methods like event history models 40 there is no clear agreement about how long a followup period is needed to get the best measurement of the effect on work and benefits after sick leave 1641 previous studies using process analyses have used a longer followup period ie 34 years 20 21 22 23 in this study only 51 weeks of followup was applied which reduces the complexity of the sequences as eg 20 with mental health reasons and 13 with other health reasons were still on sick leave and thus had not changed states thus a longer followup period would have been preferable as oyeflaten et al concluded that several years are needed to get an adequate picture of the rtw outcome 21 the frequency of mental disorders in rtw research has been found to be underestimated 44243 therefore the grouping of exposure may cause misclassification if the individuals are not true about reporting the sickness 2628 some studies have divided the sickness absence reasons into mental physical and comorbidity and found that comorbidity was associated with longer time until rtw than only reporting physical or mental problems 844 in this study individuals with comorbidity were not categorized separately as it was not the aim of the study moreover only comorbidity that was due to the sickness absence was reported therefore the degree of comorbidity in this study is unknown another limitation derives from the relatively low response rate the relationship between sickness absence reasons and employment status may have been different in nonresponders and thus could change the estimates if individuals on sick leave due to mental health reasons to a greater extent did not response to the questionnaire and at the same time were on sick leave for a longer time period we may have underestimated the association between sickness absence for mental health reasons and rtw moreover some of the clusters in fig 2 included few observations which will give rise to a large random variation generalization comparison between studies may be difficult due to the large variation between countries in the regulation of sick leave compensation and social benefits within the nordic countries the social security systems are relatively similar and make comparisons feasible 45 our findings may therefore be generalized to the nordic countries however we see no reason why the longer sickness absence periods and lower rtw expectations for those with mental health problems than for those with other health problems should not be similar in other western countries conclusion employees on sick leave due to selfreported mental health problems spent more weeks in sickness absence and temporary benefits and had a higher risk of not having returned to work within a year compared to employees on sick leave due to other health reasons the difference could be explained by their lower rtw expectations at baseline this emphasises the need to develop suitable and specific interventions to facilitate rtw for this group of sickness absentees competing interests the authors declare that they have no competing interests authors contributions pp ml tl and ll designed the study pp and ll performed the analysis pp wrote the first draft of the manuscript pp ml tl ean ll hjs and cj contributed to revising it all authors read and approved the final version of manuscript

background to investigate differences in return to work rtw and employment trajectories in individuals on sick leave for either mental health reasons or other health related reasons methods this study was based on 2036 new sickness absence cases who completed a questionnaire on social characteristics expectations for rtw and reasons for sickness absence they were divided into two exposure groups according to their selfreported sickness absence reason mental health reasons or other health reasons the outcome was employment status during the following 51 weeks and was measured both as timetoevent analysis and with sequence analysis results individuals with mental health reasons for sickness absence had a higher risk of not having returned to work rr 087 080093 adjusting for gender age education and employment did not change the estimate however after adding rtw expectations to the model the excess risk was no longer present rr 101 095108 in relation to the sequence analysis individuals with mental health related absence had significantly higher odds of being in the sickness absence cluster and significantly lower odds for being in the fast rtw cluster but when adjusting for rtw expectations the odds were somewhat attenuated and no longer significant conclusions employees on sick leave due to selfreported mental health problems spent more weeks in sickness absence and temporary benefits and had a higher risk of not having returned to work within a year compared to employees on sick leave due to other health reasons the difference could be explained by their lower rtw expectations at baseline this emphasises the need to develop suitable and specific interventions to facilitate rtw for this group of sickness absentees

introduction as of 1 october 2021 there have been 19 million covid19 cases among children 511 years in the us this has resulted in more than 8300 hospitalizations and at least 94 deaths with infection rates in children less likely to be reported than adult cases 1 as of october 2021 30 of children 511 years old were hospitalized for covid19 hospitalization rates for specific racialethnic groups were 37 nonhispanic black 31 hispanic 22 nonhispanic white and 23 nonhispanic asian 1 further hispanic and nonhispanic black children are more likely to be diagnosed with covid19associated multisystem inflammatory syndrome than nonhispanic asian and white children 2 the pandemic has thus exacerbated existing health disparities among these populations 3 this underscores the urgency of understanding how raceethnicity may influence parents decision to vaccinate their children against covid19 as of september 2021 there were no federal data on raceethnicity for covid19 vaccination rates among children 12 years and older for the seven states reporting such data nonhispanic asian children had higher vaccination rates compared to nonhispanic whites but the rates among white hispanic and black children were inconsistent 4 on 29 october 2021 the us food and drug administration authorized the pfizerbiontech covid19 vaccine for emergency use in children between 5 and 11 years of age 5 since the vaccine was approved for children 12 13 14 15 16 17 years of age us vaccination vaccines 2022 10 31 2 of 14 rates for this age group have been reported at 42 for the first dose and 32 for series completion 6 emerging data on parental intentions to have their 511yearold children vaccinated for covid19 following fda approval have reported similar rates ranging from 44 to 63 in the us 7 8 9 10 and these are consistent with data from across the globe 11 12 13 14 15 these percentages are troubling since population modeling indicates that vaccinating adolescents and children could reduce overall covidrelated mortality and case load 16 since a return to prepandemic normality is only achievable with high vaccination rates 17 these rates underscore the importance of identifying predictors of parental pediatric covid19 vaccine acceptance and hesitancy for development of effective public health initiatives the most consistent predictor of parental covid19 vaccine hesitancy in the us is lack of confidence in the safety and effectiveness of the vaccine followed by lack of trust in government and perceptions that children are not susceptible to the disease 89 18 19 20 21 22 23 demographic variables have also been associated with parental covid19 vaccine acceptance these include lower parental income and education and whether the parent has received the covid19 vaccination 9102022 a few studies have reported racialethnic differences in parental attitudes toward the covid19 vaccine for their children these include higher levels of vaccine hesitancy among hispanic and nonhispanic black parents lower vaccine safety concerns among nonhispanic white parents and higher levels of pediatric covid19 vaccination intention among nonhispanic asian parents 910182022 to date research on racialethnic differences in parental covid19 vaccine hesitancy has not included a comprehensive analysis of social determinants identified in earlier studies on parental attitudes toward childhood vaccination for longstanding diseases such as influenza rubella and hpv 24 25 26 27 28 29 30 31 these latter studies drew on health beliefs and planned behavior theoretical models to examine relationships between pediatric vaccine hesitancy and disease knowledge perceived childhood disease susceptibility and symptom severity vaccine safety and efficacy trust in government and health care providers and the influence of community norms one aim of the current study was to examine the extent to which these factors jointly and independently predict pediatric covid19 parental vaccine hesitancy for younger children the second aim was to assess similarities and differences in the salience of these predictors for hispanic and nonhispanic asian black and white parent populations methods data were collected as part of an online national nonprobability survey of 400 english speaking selfidentified hispanic and nonhispanic asian black and white female guardians of children 510 years of age there were 100 participants for each racialethnic group we selected female guardians since they have been found to be significantly less likely than males to plan to vaccinate their school age children 32 in addition female guardians are responsible for making 80 of the healthcare decisions for their children 33 although the emergency fda approval is for children 511 years of age we excluded parents with 11yearolds our rationale was that 11yearolds would soon be eligible for the prior fda emergency vaccine approval for 1217yearolds of which access to data on population efficacy and safety information for that age group is available 34 recruitment and data collection were conducted in october 2021 through qualtrics xm a survey aggregator that recruits individuals who sign up to take paid surveys a total of 1377 females responded to our screener and 977 were screened out due to failure to meet criteria for age raceethnicity or us residency respondents child was not between 5 and 11 years old raceethnicity quotas were already reached participant did not finish the survey or pass attention checks or the participant declined to consent to research participation the protocol was approved by the university institutional review board vaccines 2022 10 31 3 of 14 the primary outcome measure was the proportion of parents reporting they planned to give their oldest child between 5 and 10 years old the covid19 vaccine once it was approved by the fda and available for children under 12 response options included will definitely not will probably not are unsure probably will or definitely will 28 the survey adapted items from prior scales to assess the following social determinants of parental pediatric covid19 vaccine hesitancy covid19 misconceptions 3536 pediatric covid19 susceptibility severity of the disease for children 2737 general vaccine hesitancy pediatric covid19 vaccine safety and efficacy community support for childhood covid19 vaccination 2627 and trusted sources all items were scored on 6point likerttype scales with the exception of truefalse items assessing covid19 misconceptions demographic information included childs age gender whether the child had been infected with or tested for covid19 and parents age education household income financial security covid19 vaccination status and prior testing for or covid infection the survey items for this study are available in the supplemental materials for this article descriptive statistics for demographic data scales and intent to vaccinate are presented in tables 1 and2 the primary outcome measure was recoded into 3 categories no unsure and yes for each scale when appropriate items were reversed scored for conceptual continuity mean scores for each 6point likert type response scale were dichotomized into disagree and agree the 9item cumulative covid19 misconception score was dichotomized as low versus high level of misconception pearson chisquare tests were performed on differences among parent vaccination intentions and for racialethnic group differences for each demographic variable and items and scales reflecting beliefs and attitudes a multivariate logistic regression was performed to evaluate the percent variance and independent influence of demographic and scale scores on intent to vaccinate results overall 4075 of parents planned to have their child vaccinated against covid19 following fda approval 2475 were unsure and 3450 would not vaccinate their child as illustrated in table 1 chisquare tests indicated parents who themselves had been vaccinated for covid19 had attended college reported higher household income and financial security were significantly more likely to intend to vaccinate their children there were no differences in vaccination intention for childs age or gender figure 1 further illustrates differences in proportion of parents endorsing determinants of vaccine hesitancy by their intent to vaccinate their child against covid19 following fda approval chisquare tests indicated parents who did not plan to vaccinate their child had significantly higher levels of covid19 misconceptions perceived children to be less susceptible to infection and believed covid19 symptoms were less severe than the parents who were unsure or planned to vaccinate compared to the other groups those who did not plan to vaccinate their children had significantly higher levels of general mistrust for vaccines lower levels of confidence in the covid19 pediatric vaccine safety and efficacy reported less community support for childhood covid19 vaccination and would be less influenced in their vaccination decision by fda or their doctors recommendation parents who were unsure had lower levels of vaccine trust and were less influenced by fda or doctor recommendations than those who planned to vaccinate their children table 2 provides data on demographics plans to vaccinate and determinants of vaccine hesitancy for each racialethnic group and differences based on chisquare and analysis of variance tests nonhispanic white parents were significantly older than hispanic parents nonhispanic black and white parents reported significantly lower household income compared to asian and hispanic parents and a greater proportion of black parents reported financial insecurity more nonhispanic asian parents when compared to other racialethnic groups reported having received the covid19 vaccine vaccines 2022 10 31 8 of 14 themselves there were no other significant racialethnic differences among parental demographic variables children to be less susceptible to infection and believed covid19 symptoms were less severe than the parents who were unsure or planned to vaccinate compared to the other groups those who did not plan to vaccinate their children had significantly higher levels of general mistrust for vaccines lower levels of confidence in the covid19 pediatric vaccine safety and efficacy reported less community support for childhood covid19 vaccination and would be less influenced in their vaccination decision by fda or their doctors recommendation parents who were unsure had lower levels of vaccine trust and were less influenced by fda or doctor recommendations than those who planned to vaccinate their children table 2 provides data on demographics plans to vaccinate and determinants of vaccine hesitancy for each racialethnic group and differences based on chisquare and analysis of variance tests nonhispanic white parents were significantly older than hispanic parents nonhispanic black and white parents reported significantly lower household income compared to asian and hispanic parents and a greater proportion of black parents reported financial insecurity more nonhispanic asian parents when compared to other racialethnic groups reported having received the covid19 vaccine themselves there were no other significant racialethnic differences among parental demographic variables as illustrated in table 2 chisquare tests indicated significantly higher proportions of nonhispanic asian parents planned to vaccinate their child against covid19 nonhispanic black parents were more likely to report being unsure and significantly higher proportions of nonhispanic white parents did not plan to vaccinate their child figure 2 further illustrates differences in the proportion of each racialethnic group endorsing determinants of vaccine hesitancy compared to other racialethnic group members nonhispanic white parents reported significantly more covid19 misconceptions were less likely to worry their child was susceptible to covid19 infection endorsed less covid19 symptom severity if their child became infected and reported overall less community support for vaccinating young children against covid19 nonhispanic asian parents were least likely to report general vaccine mistrust and were more likely to endorse positive influences of the fda and physicians on their decision to vaccinate their child for covid19 across raceethnicity the majority of parents indicated some to strong confidence that the covid19 vaccine would be safe and effective for their child a multivariate ordinal logistic regression that included parental vaccine status education financial security and the hypothesized social determinants as predictors as illustrated in table 2 chisquare tests indicated significantly higher proportions of nonhispanic asian parents planned to vaccinate their child against covid19 nonhispanic black parents were more likely to report being unsure and significantly higher proportions of nonhispanic white parents did not plan to vaccinate their child figure 2 further illustrates differences in the proportion of each racialethnic group endorsing determinants of vaccine hesitancy compared to other racialethnic group members nonhispanic white parents reported significantly more covid19 misconceptions were less likely to worry their child was susceptible to covid19 infection endorsed less covid19 symptom severity if their child became infected and reported overall less community support for vaccinating young children against covid19 nonhispanic asian parents were least likely to report general vaccine mistrust and were more likely to endorse positive influences of the fda and physicians on their decision to vaccinate their child for covid19 across raceethnicity the majority of parents indicated some to strong confidence that the covid19 vaccine would be safe and effective for their child a multivariate ordinal logistic regression that included parental vaccine status education financial security and the hypothesized social determinants as predictors explained 703 of the variance in plans to vaccinate ones child parental vaccine status general trust in vaccines covid19 safety and efficacy concerns influence of fda approval and influence of physician recommendation retained significant independent effects raceethnicity retained a significant independent effect only when comparing asian and white parents p 0001 explained 703 of the variance in plans to vaccinate ones child parental vaccine status general trust in vaccines covid19 safety and efficacy concerns influence of fda approval and influence of physician recommendation retained significant independent effects raceethnicity retained a significant independent effect only when comparing asian and white parents p 0001 discussion in october 2021 2 weeks prior to the anticipated fda approval for covid19 vaccination of children between the ages of 5 and 11 years only 41 of a racially and ethnically diverse national sample of female guardians planned to have their young children vaccinated 25 were unsure and 34 were unwilling this percentage is consistent with most prior reports of covid19 vaccination rates for children 1217 years of age and anticipated rates for the emergency use approval for children 511 years of age 6 7 8 9 10 11 12 13 14 15 however rates significantly differed across racialethnic groups with 62 of nonhispanic asian parents compared to 31 nonhispanic black 45 hispanic and 25 nonhispanic white planning to vaccinate their child following fda approval this study adds to the small but growing literature on parental covid19 pediatric vaccine hesitancy by providing an analysis of factors independently and conjointly influencing parents decisions to vaccinate their children against covid19 infection and how these determinants and decisions vary across us racialethnic groups consistent with prior studies on parental hesitancy toward routine pediatric vaccines and emerging data on the current pandemic 8 9 10 18 19 20 21 22 23 bivariate analyses indicated all hypothesized demographic individual and social determinants were significantly associated with parental intentions to vaccinate their child against covid19 multivariate ordinal logistic regression demonstrated that raceethnicity parental vaccine status education financial security vaccine safety and efficacy concerns covid19 misconceptions and perceived childhood discussion in october 2021 2 weeks prior to the anticipated fda approval for covid19 vaccination of children between the ages of 5 and 11 years only 41 of a racially and ethnically diverse national sample of female guardians planned to have their young children vaccinated 25 were unsure and 34 were unwilling this percentage is consistent with most prior reports of covid19 vaccination rates for children 1217 years of age and anticipated rates for the emergency use approval for children 511 years of age 6 7 8 9 10 11 12 13 14 15 however rates significantly differed across racialethnic groups with 62 of nonhispanic asian parents compared to 31 nonhispanic black 45 hispanic and 25 nonhispanic white planning to vaccinate their child following fda approval this study adds to the small but growing literature on parental covid19 pediatric vaccine hesitancy by providing an analysis of factors independently and conjointly influencing parents decisions to vaccinate their children against covid19 infection and how these determinants and decisions vary across us racialethnic groups consistent with prior studies on parental hesitancy toward routine pediatric vaccines and emerging data on the current pandemic 8 9 10 18 19 20 21 22 23 bivariate analyses indicated all hypothesized demographic individual and social determinants were significantly associated with parental intentions to vaccinate their child against covid19 multivariate ordinal logistic regression demonstrated that raceethnicity parental vaccine status education financial security vaccine safety and efficacy concerns covid19 misconceptions and perceived childhood susceptibility to and severity of the disease community support and fda and physician recommendations accounted for 703 of the variance indicating a goodnessoffit between the model and parents plans to vaccinate their child in addition to the contrast in overall beliefs and attitudes between nonhispanic asian and white parents nonhispanic asian parents were also less likely to indicate general vaccine mistrust compared to other parents this may be due in part to the higher vaccines 2022 10 31 10 of 14 proportion of nonhispanic asian parents in our sample who themselves received the covid19 vaccine this may indicate a longstanding trust in vaccinations we also found that although significant in bivariate analyses covid19 misconceptions and perceived childhood susceptibility and severity did not sustain independent effects in the logistic regression one explanation for this finding is that the relationship between vaccine hesitancy and these two determinates was largely driven by nonhispanic white parents who proportionally reported more disease misconceptions and less susceptibility and severity concerns than other groups as discussed below these parental beliefs may be influenced by vaccine hesitant community norms taken together these findings underscore the importance of understanding racialethnic group differences in the design of effective public health strategies our study also adds to existing research by demonstrating how lack of support for pediatric covid19 vaccination from other parents family members clergy and others in ones community is a significant barrier to parental vaccine acceptance nonhispanic white parents in particular reported significantly less community support than other groups moreover with the exception of nonhispanic asian parents only a little more than half of other parental groups would find their doctors recommendation helpful in making a vaccination decision this pattern of results has implications for public health strategies that have not yet been emphasized in prior research in some segments of the us population covid19 vaccine hesitancy and uptake interventions may have negligible effects if they focus on clinicianpatient communication or expert topdown information sharing messaging for example although public service campaigns emphasize speaking to ones doctor about the vaccine for most adults and children in the us vaccines have only been available through public testing sites or pharmacies 38 thus even parents with access to a regular pediatrician may not have the opportunity or motivation to contact their physician about this decision additionally national mediabased messaging may also be ineffective for populations that traditionally distrust outside experts and or have minimal access to health providers targeted approaches for these populations may thus benefit from interventions developed in partnership with and delivered through existing trusted community coalitions such as parent support groups local political leaders and religious organizations across racialethnic groups the majority of parents thought the pediatric covid19 vaccine would be safe and effective these findings suggest that public health messaging has been successful in communicating information about the vaccine nonetheless concerns about safety and efficacy were high among parents who would be unwilling to vaccinate their child this suggests that repeated public health messaging regarding vaccine safety and efficacy alone may be insufficient to increase vaccine acceptance among individuals who may have a general distrust in government or who may be confused by the barrage of information regarding the development and testing of the vaccine although there has always been a segment of the public who distrust pediatric vaccines most parents of young children have trusted in routine vaccines for diseases of childhood which have had a long history of scientific and public acceptance 39 40 41 in many respects this is the first time the general public has had a ringside seat to the science of vaccine development and to the process of science itself including the phased nature of clinical trials the probabilistic nature of statistically significant results for treatment effectiveness and the importance of replicability this suggests that to increase vaccine uptake public health communications on pediatric covid19 vaccine safety and efficacy may need to include strategies to increase health science literacy vaccine hesitancy has been defined as the refusal or delay in the acceptance of a vaccination despite availability of the vaccine or vaccination services 40 as a consequence most studies combine into a single group of parents who are unsure and those who express unwillingness to vaccinate their child our data suggest however that vaccine uptake intervention efforts may benefit from evaluating the unique motivational needs of those who are unsure and those who are unwilling for example in our study unwilling parents compared to unsure parents were significantly less worried about childrens susceptibility to the virus or symptom severity more distrustful of vaccines in general less confident in covid vaccine efficacy and safety received less community support and were less likely to see the fda or their physician as trusted sources of information by contrast with the exception of distrust in vaccines and in fda or physician recommendations endorsements across determinants from unsure parents were not significantly different from those of parents willing to vaccinate their child against covid19 as recently suggested for adult vaccine refusers 42 our data suggest that there is a highly resistant group of parents who for multiple reasons are unlikely to be influenced by approaches for addressing vaccine hesitancy that may be successful for unsure parents rather vaccine refusers may benefit from a more comprehensive strategy that addresses the multiple and interrelated barriers to pediatric covid19 vaccination that sustains hesitancy among this population this study is not without limitations our findings are based on crosssectional data which cannot assess longitudinal causal effects of determinants on parents decisions to vaccinate their children further participant recruitment and participation were conducted entirely online through a survey panel aggregator and consequently participation was limited to individuals who have access to the internet on webenabled devices and also who have signed up to complete surveys for compensation further our data suggest that although we recruited a range of participants from varying ses backgrounds the majority attended some college and were financially secure as such our findings may not adequately represent those from lower socioeconomic backgrounds finally although our study was nationally representative and we found geographic region was not related to parental vaccination intention we did not assess rural suburban or urban differences in parental vaccine hesitancy which may be associated with lack of community support for vaccination and lack of access to and trust in healthcare providers conclusions pediatric vaccine hesitancy among parents is motivated by sociodemographic factors individual beliefs and attitudes and social influences that have unique and interrelated effects along with the unexpected arrival and spread of covid19 infection the country has witnessed a rapid pace of development of vaccines and treatments for infection accompanied by confusing government and media messaging and increased mistrust in science this combination of events calls for continued evaluation of the unique and conjoint determinants of parental vaccine hesitancy across distinct groups within the us this is especially true for the development of public health strategies to increase pediatric vaccine uptake across racialethnic groups early studies on covid19 adult vaccine hesitancy have focused on increasing uptake among hispanic and nonhispanic black adults however racialethnic disparities in vaccination rates continue to narrow especially for hispanics 4344 our data suggest that nonhispanic white populations may be at particular risk of pediatric covid19 vaccine refusal thus it is important that the racialethnic environment is considered prior to taking public health measures future research can benefit from purposive sampling that includes sufficient numbers of distinct racialethnic groups to understand unique barriers and facilitators for vaccine acceptance that can inform population tailored interventions in addition it may be important for future covid19 research and interventions to distinguish among parents who are unsure about vaccinating their children compared with those who may remain highly resistant to public health messaging identifying the motivations and effective sources of influence for this group of pediatric vaccine refusers is critical if we are to return to prepandemic normality data availability statement data supporting the reported results is provided on the fordham university download data portal at educationresearch12457pediatriccovid19parentalhesitancyandracialethnicdiversity supplementarymaterials accessed on 24 december 2021 informed consent statement informed consent was obtained from all subjects involved in the study

on 29 october 2021 the us fda authorized the pfizerbiontech covid19 sarscov2 vaccine for emergency use in children ages 511 years racialethnic minorities have born the greatest burden of pediatric covid19 infection and hospitalization research indicates high prevalence of parental vaccine hesitancy among the general population underscoring the urgency of understanding how raceethnicity may influence parents decision to vaccinate their children two weeks prior to fda approval 400 hispanic and nonhispanic asian black and white parents of children 510 years participated in an online survey assessing determinants of covid19 pediatric vaccine hesitancy compared to 31 black 45 hispanic and 25 white parents 62 of asian parents planned to vaccinate their child bivariate and multivariate ordinal logistic regression demonstrated raceethnicity parental vaccine status education financial security perceived childhood covid19 susceptibility and severity vaccine safety and efficacy concerns community support and fda and physician recommendations accounted for 703 of variance for vaccine hesitancy findings underscore the importance of multipronged population targeted approaches to increase pediatric covid19 vaccine uptake including integrating health science literacy with safety and efficacy messaging communication efforts tailored to parents who express unwillingness to vaccinate and interventions developed in partnership with and delivered through existing trusted community coalitions

introduction aboriginal and torres strait islander people are well known as having premature mortality with a substantial proportion of the life expectancy gap caused by chronic diseases with the ageing of the population and the high burden of chronic and terminal diseases among indigenous populations the need for support at the end of life is increasing the palliative approach aims to reduce unnecessary suffering by treating relieving and reducing adverse endoflife symptoms including the provision of emotional support to patients and their families palliative care considers peoples physical emotional psychological and spiritual needs and aims to achieve better quality of life for individual patients carers and families who are dealing with terminal illnesses and endoflife processes however while existing data on service use is limited palliative care is thought to be underutilised by aboriginal families with data from the australian institute of health and welfare indicating that the rate of palliative care separations for aboriginal australians is higher than for nonaboriginal australians but that their length of stay is shorter supportive and palliative care at the end of life can help alleviate stressors in caring for a terminally ill family member and assist families to deal with some of the grief and stress associated with death lack of understanding of the role of palliative care poor availability of palliative care services other serious health problems family issues cultural incongruity geography and service distribution may all be reasons why endoflife care is underutilised as identified in a recent systematic review on palliative care service delivery to indigenous peoples in specified countries there is little research on endoflife issues for aboriginal australians other than that conducted in the northern territory focused on what health services need to do to meet the requirements however it is important that when delivering services in a crosscultural context there is a deep understanding of peoples underpinning beliefs and wishes as part of understanding how services could respond to those needs fundamental to effective palliative care service delivery is an informed health sector that understands the issues and concerns of patients and their families in their larger sociocultural context this will enable provision of appropriate care that focuses on quality of life for people with a lifelimiting illness and their families the present article reports information collected in two distinct ways the first component was a scoping study based upon a series of workshops undertaken in community and professional settings in the midwest region of western australia at sites located more than 400 km north of perth the capital of western australia the aim was to engage local aboriginal adults who were living and working in community settings to talk frankly about their wishes and concerns around endoflife issues and to distil key themes and approaches that could inform wider discussions and interventions these participants were a mixed age range and were healthy that is not selected because of illness information from these community consultations was supplemented by analysis of video interviews undertaken with aboriginal people with cancer which often included discussion of their thoughts and wishes related to end of life this approach enabled broader insights into endoflife issues for aboriginal people and included people with health conditions which meant they were more directly confronted by their own mortality methods component 1 deliberative discussions on endoflife care team the team included a local aboriginal woman who had grown up in the region and was widely known and respected her role was instrumental in the engagement of community members she had been involved in the project described in component 2 in which local aboriginal people with cancer were videorecorded as they spoke about their experience of cancer conversations that included endoflife care issues other team members included two researchers with many years of experience working with aboriginal people and of aboriginal people living with cancer the team collaborated with two people with a background in performing arts who helped to facilitate public forums they had there for another person this requires listening with awareness to participants and validating their experience without judgement and without trying to make it all ok the facilitators role was to be present reflective allow the free flow of ideas knowledge tensions and dissonances and to be attentive to what was said and to the unspoken settings and participants all meetings were paced to allow opportunities for small and larger group discussions in a safe space to enable those present to contribute to the extent that they chose formal and informal discussions occurred within larger meetings community there were four meetings in community settings three with high aboriginal engagement including one at a mens shed in a town 100 km from the regional city and two at an aboriginal community resource centre because the fourth site did not include aboriginal participants it is not included in any further analysis in addition to the community meetings facilitators and researchers had an informal lunch meeting with local aboriginal artists in a large meeting room at the authors workplace this approach recognised the facilitators experience of artbased approaches in ceremony and creating memories to honour ancestors family and friends who are dead although attendees at meetings may have chronic diseases they were not selected for any health condition or invited because of any particular interest expressed around endoflife issues public a group public forum was held for the broader community to engage in conversations about death and dying invitations were sent to key community members and the event attracted interest from a diversity of people including those working in the funeral industry palliative care volunteers chaplaincy community and arts sector workers in palliative care and care for the aged health science students and health professionals involved in service delivery and education two aspiring death doulas were among the attendees group work included use of go wish a sorting card game to help users start a conversation about end of life in which they can express their wishes in life and at the end of life paper and pencil activities and discussion of some written material pertaining to emotional wills in which a person expresses matters important to them regarding their legacy beliefs and achievements health service providers team members visited a number of sites to discuss issues around death and endoflife choices these included the local aboriginal community controlled health service a regular professional development forum attended by a multidisciplinary health team the regional palliative care team and the cancer centre at the regional hospital synthesis of themes debriefing and extraction of key issues and themes followed each meeting the findings reported consolidate distilled perspectives representing the consensus of the facilitators and researchers based upon notes observations discussion and refinement of draft themes where there were discrepant views among participants these are highlighted the triangulation of data from both community and other professional meetings revealed considerable commonality in uncertainty conflict and concerns that aboriginal people face dealing with death component 2 analysis of videos of aboriginal patients with cancer as part of an earlier research translation activity members of the team had with signed consent from participants made a series of videos of aboriginal people with cancer primarily for educational purposes the interviews were freeflowing and loosely based on an interview guide that allowed for exploration of endoflife issues participants were recruited by a local aboriginal woman and team member there were 10 aboriginal participants in total eight people with cancer and two with women who had played a major role in an aboriginal cancer support group that had supported aboriginal people as they approached death only one participant was not a resident of the region where the community consultations occurred all videos were reviewed with respect to endoflife wishes with relevant comments identified and transcribed key themes were identified by familiarisation with the data generating codes and identifying and refining themes based upon discussion among the team ethics approval the project was undertaken as part of a broader research project to examine the distinctive needs of aboriginal people with cancer including issues around endoflife care for which ethics approval was granted by the western australia aboriginal health ethics committee and the university of western australia results component 1 discussions on endoflife care with community and service providers the format of each gathering was determined by the nature and makeup of the group and the physical surroundings the neutral outdoor meeting space at the aboriginal community resource centre was hospitable and conducive for the conversation with evident appreciation of taking the discussion to a site where people regularly gathered and talked generally having informal and personal conversations while waiting for the full group to gather before the start of the group conversation gave time for the facilitators to land gently and gain their bearings these informal exchanges provided insights as to how to introduce the conversation topic talking about death at the community meetings the men were initially reluctant to speak about death because there was too much trouble surrounding this issue aboriginal relationships and kin ties are complex and one death in a community was seen to affect many people as there are many deaths grieving can seem like a constant state however when questioned further all agreed that deaths in the community often became the cause and focal point for feuding and arguments strong beliefs existed regarding what should occur after a persons death and many were concerned that the right thing is not always abided by or even agreed on by everyone some expressed the strong belief that a person should be buried whole and at their rightful resting place although where that rightful resting place might be was often a cause for dispute even when a person had made their wishes known as to their final resting place arguments could still occur if others who might claim a more respected position in the community deemed that those wishes were not culturally appropriate another reason given for not speaking openly about death was the fear of jinxing oneself or ones loved ones the reluctance to talk about death was understandable if they believed that by avoiding talking about it they could keep death further away concerns previously reported for aboriginal people as one aboriginal leader noted people are closely connected in the aboriginal community and one death affects many and there are many deaths however reluctance to speak about death was also often based on sensitivity to family troubles and feuding which could be exacerbated by differences of opinion regarding financial responsibilities and level of care for the loved one before and after death the meeting with community artists provided the opportunity to show audiovisual and website material that enabled insights into celebrations around approaches to death that occur elsewhere in australia this promoted rich discussion based upon the work of the lead facilitator in a previous project honouring our dead there was resonance with the ideas of creative artistic and professional collaboration to honour loved ones in a place and manner appropriate for the person the group recognised the need for an outdoor area community cultural development and rituals that are appropriate and meaningful the artists reviewed the go wish cards to help facilitate discussion about priorities and wishes the cards encourage participants to talk about their endoflife care and wishes what is important and why by sorting them into piles of three categories very important to me somewhat important to me and not important to me this allowed participants to talk about their wishes and preferences for care at the end of life the basis for this is the idea that talking can reduce stress at the time of a serious illness and help families understand a persons preferences none of the participants had previously been introduced to the use of such card sorting in reflecting on priorities around values and dying areas that were trigger points for particularly lively discussion included wills funerals and burial versus cremation making a will emerging from all consultations was the issue of making of wills for aboriginal people in western australia which had been a matter for concern since the aboriginal affairs planning authority act 1972 ruled that the estates of those aboriginal people dying intestate be administered by the public trustee to aboriginal people this ruling was seen as racist and demeaning when the rest of the australian population was not bound by such a law after much work in the mid2000s and many submissions to the minister the ruling was repealed in 2012 a local agency whose role had included providing social and legal support for aboriginal people had run a project for 2 years called the aboriginal wills project with funding support from a large legal firm the focus of the project had been to educate aboriginal people on the importance of will making and to assist them to make a valid will this was based upon the understanding that a valid will can proactively minimise conflict within the willmakers family by making clear their wishes regarding issues such as place of burial funeral arrangements and the passing on of special property such as artworks music artefacts and other unique personal items because the project was a free service it had aimed to provide aboriginal people with information on and assistance with things such as superannuation life insurance and funeral plans it also provided assistance with advanced health directives enduring power of attorney and enduring power of guardianship according to the director of the agency many aboriginal people used the service during the time of its operation but unfortunately the project was discontinued due to lack of ongoing funding rather than to lack of interest the aboriginal community and the agency were keen to relaunch the project if funding became available where to die most of the participants seemed to assume that people would die in hospital rather than at home of note was that cancer care and palliative care were associated with imminent death those who knew about the local hospice held it in high regard and cited this as their preferred option dying supported by extended family and where they would feel free to do traditional stuff playing music singing was important taking me back home to my own country to be buried on country was noted by some as important organ donation organ donation was not generally discussed but was raised in the professional development academic meeting the topic proved to be confronting to an aboriginal attendee at the meeting who was horrified when asked if she would consider donating other participants reported having witnessed similar reactions some acknowledged the importance of raising awareness about organ donation in aboriginal communities given the high numbers of aboriginal people receiving renal dialysis who could benefit from an organ donation although the donatelife website has a range of resources designed for aboriginal communities these were not known to the participants cost of funerals funeral plans funeral directors funeral costs and culturally respectful funeral industry practices arose as significant concerns there was concern regarding the cost of funerals the local aboriginal community controlled health service provided support to families following a death and the ceo was a strong advocate for funeral insurance or prepaid funeral plans a local funeral parlour well known to the aboriginal community facilitated loans to enable borrowing between 4000 and 25000 to cover funeral costs repayable over 1860 months it was difficult to see how many aboriginal families could meet the criteria to obtain such loans or meet all the payments another funeral service was criticised by some community members as the directors used maori language and concepts in the funeral ceremony culturally focused aboriginal community members reported that their approach clashed with their own aboriginal values however this funeral service advertised helpful information and options for a full range of services including the least expensive funerals funeral insurance and bonds a final resting place or scattering to the winds peoples wishes relating to being buried or cremated provoked the most discussion with many participants stating emphatically that they wished to be buried however there seemed to be generational differences with younger people being open to cremation and older people more emphatic in stating that the only way is burial those with strong views on burial also had strong views regarding which cemetery to be buried in following discussion on cremation and the reasons for the distaste for cremation it appeared that some people conflated cremation with scattering to the winds a kind of dispersal of spirit as well as body a recent incident of negligent and unlawful work practice at the regional crematorium regarding disposal of bone remains had been reported in the media and contributed to a lack of confidence regarding cremation wishing to be buried on country was a strong incentive but questions arose about what that meant in practice should their resting place be where they were born where they grew up where they live now or where their kin are buried for some who had ties to a number of places the idea of allocating ashes to separate places seemed to provide a possible way of resolving this particular issue funeral services although it remains customary to have a church funeral service some aboriginal people are now opting for a civil funeral service one young person who claimed he was not churchgoing reported he had such a connection with the catholic church in his local community that he wanted his funeral to be held in that church given this tie to tradition with the catholic church it is possible that resistance to cremation reflects church teachings that encourage burial of the body and forbid the scattering of ashes some participants voiced dissatisfaction around the disrespectful manner in which a loved ones body was handled in transfer further concern was expressed about the speed at which graveside and chapel services were conducted in order to keep within the allocated time volunteers neither the aboriginal controlled community health service regional palliative care nor the cancer centre has a formal volunteer scheme to provide support to families with a dying family member or who have recently been bereaved a support group primarily directed at supporting patients with cancer had operated in the region in the past and had played a major role around endoflife and bereavement support its failure to be sustained reflected challenges with resourcing status and intercultural and interorganisational partnerships however the key agencies listed all agreed that a welltrained volunteer corps would be beneficial if there was the infrastructure to support it this raises the possibility of a coordinated approach to volunteer training that could foster closer links between the groups emerging possibilities for the future at two community sites some participants were involved in the work for the dole scheme following discussions at the mens shed about the expense of coffins the possibility was raised that these could be offset by offering communitycrafted ones following initial concern expressed by some the discussion became more positive with genuine willingness to consider the proposal while relevant acts of western australian law have little mention of regulation regarding coffin construction the funeral directors association also has requirements which appear to make home coffin construction difficult but not impossible the second visit to the community resource centre highlighted that conversations had continued after the facilitated discussion had ended the first visit had prompted discussion of the possibility of the centre taking a lead in creating a memorial space and a notforprofit funeral service specifically for the local aboriginal community within 2 days the centre management had identified a possible memorial site incorporating a community garden and was preparing to put the proposal before the organisations board given the reported and initial reluctance of the aboriginal community to talk about death considerable interest was shown in the potential for creative community memorial ceremonies in consultation with community members one idea was to have community picnics or ceremonies to talk about death and celebrate the life of loved ones to be held in places congruent with family and community values opportunities to partner with local yamaji artists emerged through a number of possibilities including working to customise the go wish cards for local people support for a dying to know day and the involvement of the external expert facilitators in further death literacy conversations and training component 2 themes identified in the cancer videos the community recognised that terminal illness has enormous impact on friends and family and that endoflife issues are difficult for all people participants reported that people are concerned that if they die away from country their spirit will not find its way back funeral issues were identified as sometimes contentious with some participants highlighting the importance of families knowing what a persons wishes are and understanding the importance of carrying out those wishes as one participant stated families can have a feud over this so its important for your family to know your wishes views were not uniform despite one person commenting not much decision making to be had when you die you must be buried back home and kids know this its an unspoken rule all own their own burial plots message to others is to encourage people to have the conversation lots of aboriginal people dont like talking about death and many used to think that talking about death would put a curse on you one woman was adamant about wanting to be cremated but several were equally clear that they wanted to be buried where their elders and family are another woman spoke of wanting to be buried where her brothers and her son are buried so that people can go and see me and talk to me just like i still go and talk to my mum the importance of talking with family was reiterated many times a woman with older children and grandchildren reported how challenging it was to get support from children who had difficulty in coping with the diagnosis this made it difficult to talk to her children about death and dying and endoflife wishes yet she stressed the importance of discussing certain issues … finalise any outstanding business do your will and let the family know where and how you want to be buried and where you want to be in your final days at home or in hospital another participant commented on the need for support … it is important to have someone with you when the doctor tells you about what you can expect with regards to treatment and outcomes … dont be frightened to talk and dont be afraid to ask for help if you need it another person advised take time for yourself look after yourself you are the cog in the wheel of your family interviews with those diagnosed with cancer indicated that while participants were keen to remain positive and think you can beat this and trying not to think about the end of life there was also considerable insight into the need to prepare their loved ones as one woman whose family included young children stated prepare kids for the worstcase scenario especially when you still look well important to have your family with you especially the little ones … be prepared but carry on as normal when you can participants also noted the need for hospitals to be more accommodating for aboriginal people who are dying allowing their family to be around the person service providers and others need to have adequate cultural understanding understand where people are coming from their limitations and language difficulties the need for cultural respect where people had options and were allowed to express their own preferences was noted rather than letting people … tell you what to do those interviewed felt that increasing the numbers of aboriginal people working in cancer and palliative care services could be a means of achieving this an improvement in education for aboriginal people to assist in overcoming barriers on denial and nonacceptance and to put an end to selfblame was recommended and it was noted that aboriginal primary healthcare services were well placed to provide good education and screening services one participant referred to difficulty in discussing what type of care you want when things get worse and another talked about the important role palliative care could play in having the conversation … breaking the taboo remaining respectful but modernising the conversation the local palliative care service was acknowledged for their help with development of a memoryeulogy book with messages and photographs for others to remember them by this allows people to say the things that are important to their loved ones most participants had an opportunity to view their own video some used the video to show their family including one who had reported that her family was not coping with her illness the grandchildren replayed the video to the family after her death as there were differences of opinion relating to funeral arrangements and arguments occurring with respect to implementing the persons wishes another participant had the video shown at her funeral discussion despite premature loss of life experienced by aboriginal people in australia little information is known regarding their attitudes to endoflife discussions and their use of and experiences related to endoflife care the australian literature related to palliative care and aboriginal people is small and to date been largely reported on the experiences of aboriginal people in the northern territory including issues such as dying on country despite some initial reticence to opening up on these issues reflecting that such conversations are not common in the safe space within the community settings many participants warmed to the discussion the experienced facilitators demonstrated that experiencing death is not only something that takes away from the affected family but also that experiencing and talking about death can be life enhancing importantly the approach occurred in a way that allowed for a diversity of views to be expressed this was particularly so in the group of local artists where interest was shown in looking at how people elsewhere in australia had creatively found ways to honour a persons memory after they had died as part of celebrating their life the second group of participants each had a lifethreatening diagnosis so were closer to confronting their own mortality their thoughts related to end of life reflected having given serious consideration to the issue and recognition of the challenges in talking to others about their own wishes these conversations were contained within longer reflections on their experience of cancer and cancer care so it is unsurprising that thoughts related to provision of health services talking with family and being clear about their own wishes emerged as central considerations these were largely consistent with findings related to palliative care services reported for indigenous peoples across other developed countries within both groups involvement of family was an important consideration in terms of family being around involved in decisionmaking and supporting their care family presence and involvement in decision making and care has been described for australian and other indigenous populations while not explicitly mentioned this may reflect some element of recognising and deferring to the cultural knowledge and personal authority of family members and relevant others within the aboriginal community that fried referred to as necessary concomitant with family involvement was the importance of family respecting an individuals preferences for their care and their preferred arrangements following death issues that have been identified previously areas where there were differences in personal beliefs and wishes leading to family tensions occurred around funerals and where there were strongly held views about burial versus cremation including the appropriate place where a person should be buried even when families agreed on burial this reflects that in modern society many aboriginal people are mobile and often have lived much of their life away from their country having moved for education employment relationship or family reasons the notion of returning to ones country was evident in discussions but because the discussions occurred in the midwest of western australia with people from the midwest region this issue received relatively little attention what surfaced as more of a potential issue occurred for people who had moved to the city for treatment and died away from home the local aboriginal community controlled health service provided assistance in repatriating bodies to the region for burial which helped to overcome this problem it is likely that like other rural residents preferences around place of death change with time so that dying in a safe place becomes more important than dying at home a safe space includes familiarity and attention to physical spiritual family and cultural needs the cost of funerals emerged as a significant issue participants showed considerable interest in the possibility of a mens group making coffins as a way to reduce costs and indicated an interest in personalising the coffin by having family and friends decorate it opportunities to honour those who had died through appropriate and respectful events held at a place away from a church or graveyard and where the community could come together to celebrate their lives received considerable interest several practical challenges would need to be overcome for these ideas to be realised yet with support and facilitation they are achievable and could enable opportunities for further conversations that help people deal with death and bereavement most aboriginal people are regularly dealing with grief and loss exacerbated by aboriginal people often dying prematurely which adds to many other life stressors some of the loss relates to sudden death from injury yet many are dying from chronic diseases cardiovascular disease cancer diabetes renal failure and respiratory diseases where expressed and supported preferences around endoflife care can help improve a persons quality of life as they approach death opportunities to talk about grief and loss can be helpful in coming to terms with loss whatever the cause palliative care australias dying to talk resources targeted at aboriginal people offer opportunities to support individuals and communities to have discussions about endoflife preferences the extent to which these have been taken up and used with aboriginal people is unknown yet the authors engagement with aboriginal groups in the midwest suggests they are likely to be useful as conversation starters and that within a safe environment opportunities to talk about endoflife wishes and issues are welcomed conclusion while much has been written on the need to improve culturally appropriate endof life services for aboriginal people many people remain reticent about conveying their death and dying wishes to those closest to them ceremonies around death play a pivotal role in the lives of aboriginal people and finding acceptable ways for people to pass on their wishes to their loved ones is important to avoid the stress and family conflict that may occur following death use of sorting cards to promote discussions about end of life with experienced facilitators who are comfortable talking about life and death proved useful in encouraging conversations about endoflife wishes in aboriginal people these brought up areas of tension where further group discussions are needed to create better understanding of the differences in personal views the two projects both highlight the opportunities that exist to use the arts as a means of engaging with public discussions around endoflife wishes and honouring people as a means of helping those coping with the grief of bereavement this pdf has been produced for your convenience always refer to the live site for the version of record

introduction indigenous patients with lifelimiting conditions have complex needs experience reduced access to and uptake of treatment and have lower utilisation of palliative care services than the general population lack of understanding of the role of palliative care and poor availability of culturally safe specialist palliative care services impact on indigenous peoples endoflife decisionmaking methods to understand aboriginal peoples perspectives and experiences at the end of life an exploratory study using facilitated group discussions in community settings in a region of western australia was undertaken local aboriginal people were engaged to talk frankly about their wishes and concerns around end of life the community consultations included two meetings at the local aboriginal corporation an evening meeting for invited community members a meeting at the local aboriginal community controlled health service and two further meetings of community members at local gathering places these were supplemented by the analysis of previous indepth videorecorded interviews that were undertaken with aboriginal people with cancer reporting on their concerns and wishes rural and remote health rrhorgau

stereotypes have long been treated within social psychological literature as having a moral dimension this is reflected implicitly in the accumulation of a substantial literature examining theoretical and empirical links between stereotypes prejudice and discrimination as well as in longstanding efforts to examine changes in stereotypes and to develop effective stereotype negation or reduction interventions thus by attending to possible links between stereotypes and social problems such as prejudice and discrimination and by seeking out ways to eliminate or reduce stereotypes researchers have implicitly treated stereotypes as morally problematic objects this implicit treatment of stereotypes as moral objects has also historically been taken up more explicitly by some authors who have attempted to specify precisely whether and why stereotypes should be regarded as wrong brown asked is it possible that the social psychologist has used the word stereotype to stigmatize beliefs of which he disapproves but which he does not know to be false has he sic perverted his science to achieve a moral purpose similarly campbell suggested that stereotypes are unacceptable because they result in unquestioned and biased assumptions about outgroup members serve to attribute exaggerated homogeneity to groups and underestimate overlaps between different groups and result in erroneous causal attributions one of the early debates in the stereotype literature involved the question of whether stereotypes must contain a kernel of truth to endure over time or whether they are necessarily false with this question of the accuracy of stereotypes subsequently being treated as having implications for whether they should be seen as objectionable for example myers suggests that a n accurate stereotype may even be desirable we call it sensitivity to diversity or cultural awareness in a multicultural world…the problem with stereotypes arises when they are overgeneralized or just plain wrong as i demonstrate in my below analysis of exchanges in which speakers produce possible racial stereotypes this link between the accuracy and moral status of stereotypes is a treated as a relevant consideration not just by social psychologists but also by ordinary people as they deploy stereotypes and manage their moral accountability in everyday interactions i turn first however to a consideration of how social psychological researchers have recognized and worked to manage the moral dimensions of stereotypes in their research practices managing the moral accountability of stereotypes in research practice there has been longstanding recognition of the potential importance for researchers of their participants treatment of stereotypes as morally objectionable this is reflected in researchers concerns that participants may be reluctant to openly express stereotypes as a result of the negative judgments of them that may result from such expressions for example sigall and page suggested that the apparent fading of students endorsement of ethnic stereotypes in studies conducted following katz and bralys original study of this topic may have been a result of emerging social desirability considerations with respect to the expression of such stereotypes it has since become commonplace for social psychologists to assume that normative constraints that have emerged in recent decades against the open expression of attitudes and stereotypes have shaped whether and how research participants might express or endorse them this is further reflected in social psychological theories of such as symbolic racism and aversive racism which take modern normative constraints against the open expression of negative attitudes or stereotypes as a point of departure for theorizing the emergence of particular forms of modern racism in light of concerns surrounding socially desirable responses to measures of stereotypes social psychological researchers have worked to develop approaches to measuring them while avoiding or minimizing social desirability effects an early approach in this regard was the matchedguise technique developed by lambert and his colleagues in their pioneering research on language attitudes this technique involved asking participants to rate the personality characteristics of the speakers of recordings in two different languages with participants being unaware that the same speaker was the same individual in both recordings this was designed to elicit stereotypes associated with particular languages by virtue of revealing participants more private reactions to the language being spoken under the guise of evaluating the individual speakers in the recordings another early innovation in this regard was sigall and pages bogus pipeline technique which involved informing the participants that the experimenter had access to the precise direction and intensity of their beliefs in the accuracy of particular ethnic stereotypes via direct physiological measurement using a machine to which the participants were connected participants were then asked to predict what the physiological measurement would reveal and it was assumed that they would respond accurately and honestly on the basis of the presumption that the experimenter would know their real beliefs anyway and in order to avoid being seen as deceptive or insensitive to their own feelings this approach allowed for continued direct measurement of participants endorsement of stereotypes while including a mechanism designed to ensure that the measure accurately reflected participants true beliefs rather than socially desirable responses while direct selfreport measures have remained widely in use more recent developments have seen the widespread adoption of indirect measures as a means to address social desirability for example the implicit association test or iat measures the relative strength of pairs of stereotypic associations using speed of response as a proxy for strength of association thus it is assumed that measures of the speed with which participants make stereotypic associations compared to nonstereotypic associations can indicate the strength of participants endorsement of stereotypes without the measurement being compromised by socially desirable responding as these examples demonstrate the moral accountability surrounding the expression of stereotypes has tended to be viewed within conventional social psychology as an empirical inconvenience a threat to the validity of measures of stereotypes rather than as an integral part of the nature of stereotypes this view is underpinned by and has developed concurrently with the dominance of a cognitive approach to social psychology in general and stereotypes in particular within this approach it is assumed that stereotypes are essentially cognitive objects generalized beliefs about the characteristics of members of a social category regardless of whether they are seen as operating at a conscious or unconscious level a consequence of this social cognitive view is that although the socially shared nature of stereotypes is recognized they are treated as being effectively located in the cognitive structures and processes of individuals similarly the activity of stereotyping is effectively treated as a cognitive process that takes place in the minds of individuals rather than being produced in a social arena the task for researchers wishing to examine stereotypes is thus seen as requiring ways of accessing in as uncontaminated a form as possible their essential cognitive core within individual research participants when studied in this way stereotypes are stripped of the social context of their expression and the moral accountability associated therewith that is despite the implicit and explicit recognition of the moral character of stereotypes their moral dimension is treated as something to be controlled or bypassed rather than being subjected to direct examination 1 an alternative to the dominant cognitive approach to social psychology has been articulated primarily by discursive psychologists drawing on ethnomethodological and conversation analytic approaches and findings a central feature of this alternative approach is the respecification of psychological topics in terms of situated discourse practices analytic attention is thus focused on how participants use and manage psychological concepts and concerns in practical ways to produce particular actions or outcomes in a range of everyday and institutional interactional settings this includes attention both to the ways in which concepts developed within professional or academic psychology are taken up or oriented to by speakers in everyday interactions as well as psychologists use of everyday language and concepts in their research and professional practices the discursive psychological approach has been relatively extensively applied to the study of how matters of attitudes and prejudice are managed in talk including in cases where matters of race and racism of the type i examine below are at stake it has also been used to examine the deployment of stereotypes in interactions including what they are used to do by those producing them how they are responded to by recipients and more basically what kinds of expressions are treated as stereotypes in the first place in this way the phenomena that researchers employing the social cognitive approach seek to control or bypass become objects of direct analytic attention and the social context of stereotyping is recognized as a central focus of investigation rather than an empirical inconvenience as far as i am aware however no previous research has employed this approach to examine how the relationship between the moral accountability and the accuracy of possible expressions of stereotypes is interactionally produced and managed as a participants concern and this is therefore the focus of the analysis that follows data and method the excerpts presented below are drawn from a dataset consisting of approximately 120 hours of broadcasts from three south african radio stations which were recorded as part of a broader study of the use and management of racial categories in everyday talkininteraction it is noteworthy that south africa is the site of a relatively recent transition from a rigidly legislated racialized social order to an avowedly nonracial democratic dispensation but one where race nonetheless continues to feature centrally in public discourse thus as a readily available source of everyday discussions of topical issues that participants recurrently treat as intersecting with race in various ways radio callin shows from south african stations provide an ideal setting for the examination of the interactional production and management of racial categories the recordings on which this study was based were produced primarily between 2006 and 2008 with supplementary recordings added between 2011 and 2015 it should be noted that these data come from a particular institutional setting which is observably relevant and consequential in many of the details of the talk produced by the participants although these institutional features are not primary phenomena of interest for the purposes of the analysis reported below and i thus generally address them only as and when they become analytically relevant one particular feature of this setting makes it a useful site for the examination of the moral accountability of stereotypes this feature relates to the role of the hosts of the shows who tend to work both to maintain a neutralistic stance and to moderate callers talk and police the expression of particularly extreme utterances which includes monitoring callers talk for utterances that members of the overhearing audience may find objectionable and acting as a representative of the audience in responding to such talk this provides a systematic basis for sanctioning callers who objectionably express stereotypes and thus the relatively ready availability in the data of exchanges in which speakers are held accountable for their production of stereotypes while the ways in which these processes unfold may in some ways be specific to the talk radio setting it is likely that the bases upon which participants come to treat possible expressions of stereotypes as objectionable and the ways in which they respond to them would potentially be available as resources for participants in a wider range of contexts the data set as a whole includes over 620 stretches of interaction in which one or more racial categories was either explicitly mentioned or implicitly oriented to and the analysis that follows is based on a more specific collection 57 exchanges in which possible instances of racial stereotypes were produced and responded to i identified these exchanges by searching the data for places in which speakers produced categorybased generalizations that served to associate members of a category with a commonly known or typical attribute or set of attributes it is important to note however that consistent with this focus on how stereotypes are produced and managed as a participants category i based my identification of possible stereotypes on participants orientations to these kinds of categoryattribute links rather than rigidly applying an a priori definition as such this approach to identifying possible stereotypes was applied as an analytic strategy for the purposes of building a collection of stretches of interaction that were potentially relevant for the purposes of the present analysis rather than as a means of definitively settling whether a stereotype had been produced during any given exchange my analysis draws on conversation analytic and discursive psychological approaches to examine the interactional trajectories that follow the deployment of possible racial stereotypes in the production of ordinary actionsininteraction in particular i consider the bases upon which such stereotypes may be challenged or accepted by their recipients and thus how their moral accountability is oriented to and managed by the participants as noted above the participants in the data recurrently treated the accuracy of categoryattribute associations as being a primary basis for judgments regarding their moral status it is important to emphasize however that i use the term accuracy here not to refer to an objective sense of whether or not a particular association is empirically factual but instead as a participants category that is i consider how participants make and contest determinations regarding the accuracy of possible stereotypes in the momentbymoment unfolding of the interactions and how they use these determinations as bases for negotiating the moral accountability of stereotyping independently of whether the stereotype is objectively accurate the data excerpts shown in the following section were transcribed using the detailed conversation analytic conventions developed primarily by gail jefferson which are described in detail in jefferson the excerpts were selected in order to exemplify both the recurrent features of the phenomena of interest and the range of variation in their realization across different cases analysis in excerpt 1 2 a host morally sanctions a callers expression of a stereotype explicitly treating its inaccuracy as the basis for this sanctioning prior to the transcribed section of the call the caller has complained about a highprofile political figure who had reportedly made derogatory comments about the proportion of students of indian descent enrolled at a large south african university and the host has aligned with the callers complaints and has sympathized with the outrage he has expressed as he continues with his complaint the caller then produces an apparent stereotype of the african community being brought up with hate with no father care in response the host immediately and interruptively disagrees with the caller thereby displaying strong disagreement with his utterance and treating it as unequivocally objectionable after somewhat mitigating the strength of his disagreement the host goes on to explicitly identify the callers act of generalizing as the basis for his objection stating that such an action is just incorrect the host thus resists the commonsense categoryattribute link the caller has produced treating generalizations of this sort as either factually inaccurate or morally incorrect or both following two short pauses separated by the hosts addition of the word basically to his prior claim the host further elaborates the basis for his disagreement with the caller in lines 1315 more explicitly morally sanctioning the caller in the process specifically the hosts use of the word cant clearly refers to a moral proscription against generalizing rather than a literal inability since the host is referring to something that the caller has just done as opposed something that he would actually be unable to do it is also noteworthy that following these statements about what the caller cant do the host suggests that we all know that thereby proposing that it is common knowledge that the kind of thing the caller has done is morally problematic and hence should not be done he thus treats stereotyping of the sort the caller has engaged in as being commonly known to be morally wrong in addition the host goes on to describe the conflict that would predictably result from overhearing listeners taking issue with what the caller has said thereby further underlining his treatment of the morally problematic nature of stereotypes as widely knownincommon while orienting to the importance of managing their public expression in order to avoid the kinds of conflicts that could result from it in excerpt 2 a caller produces a complaint that in the context of the discussion in which it is produced potentially implies a stereotype of black people albeit without stating it directly in the way the caller in excerpt 1 did in this case the host more explicitly formulates the stereotype apparently implied in the callers utterance which eventually leads to sanctioning with similar features to that produced by the host in excerpt 1 this excerpt is part of a longer discussion sparked by a controversial newspaper column that was widely condemned on the basis that it perpetuated negative stereotypes of black south africans but was defended by others the excerpt is thus situated in a context of contestation over the expression of stereotypes which the host apparently uses as a basis for his treatment of the caller as having deployed an inaccurate and hence objectionable racial stereotype excerpt the caller constructs her complaint by describing an incident reported on the news the same night regarding the arrest of two men who had allegedly raped a threeyearold apparently based on a belief that doing so would protect them from contracting aids resulting in the death of the child while the caller makes no explicit mention of race in her description of the incident the context of its production provides for a hearing that she is treating the rapists actions as category bound to the category black south africans and thus that she is implicitly treating this category as the basis for their actions moreover the callers question in line 9 more explicitly refers back to the racialised discussion of the controversial column including her own defense of the columnist and her claims that the column was not racist this question thus implements a complaint about the discussion and criticism surrounding the newspaper column with the report of the rape being mobilized as evidence that this criticism was unfair and possibly that the depiction of black south africans on which the criticism was based was in fact justified consistent with this analysis the hosts response to this complaint by the caller indicates that he has heard it as constituting an implicit expression of a racial stereotype following his initial displays of recognition of the story to which the caller was referring the host first begins to respond in line 8 projecting through his use of the word but that he is headed towards a disagreeing response he then abandons this response after the caller begins talking again in overlap with him before restarting slightly in overlap with this question in line 10 with his repetition of the words not only from his turn showing this new utterance to be a restarted or recycled version of the utterance he abandoned at line 8 in completing this response the host states that not only black people rape children thereby treating what the caller has just said as constituting an implicit expression of a stereotypical association between the categories child rapist and black in this way the host disagrees with the caller while resisting the categoryattribute association she has apparently produced and treating its inaccuracy as being the basis for his disagreement following this initial response by the host the caller has a number of opportunities to correct his interpretation of what she said specifically she passes up the chance to respond during a brief pause immediately following this response and then similarly passes up further opportunities to respond at lines 14 and 16 even after the host has twice pursued a response from her thus although each of the hosts utterances between lines 1011 and line 15 creates a place at which the caller could deny that she was expressing a stereotype she passes up all of these opportunities to do so and thereby tacitly confirms the correctness of the hosts hearing of her previous turn she then explicitly confirms the hosts hearing by defending the accuracy of the stereotype the hosts articulation of the stereotype by specifying those being stereotyped as people who rape children so that they wouldnt get aids the host then quickly responds starting to speak slightly in overlap with the caller and beginning to describe what will happen if were gonna start saying things such as she has said to be headed towards a formulation of the consequences of claims such as that produced by the caller which would constitute a rebuke of the callers actions he does not complete this formulation however as the caller interrupts him to suggest that they leave that topic before thanking the host and hanging up shortly afterwards the caller thereby abandons her pursuit of her complaint in the face of the apparently imminent moral sanctioning by the host albeit without explicitly backing away from the stereotype she has deployed in producing it after the caller has hung up the host produces further evidence that he was headed towards sanctioning of her actions firstly he agrees with her request to leave that topic suggesting that they should not go down that route right now as the result would be some interesting fisticuffs thereby pointing out that her actions would be likely to result in conflict moreover in rejecting the racebased causal attribution that he proposes the caller to have made the host further treats it as morally problematic by using the word cant in a similar way to that of the host in excerpt 1 thus as in the previous case this excerpt demonstrates the situated production of a link between the accuracy of a stereotype and the moral accountability involved in its expression particularly with respect to importance of avoiding the conflict that could predictably result from it while the speaker who expressed the stereotype in excerpt 2 eventually abandoned the action she was pursuing when faced with moral sanctioning excerpt 3 demonstrates that moral sanctioning of a possible expression of a stereotype may subsequently be withdrawn on the basis of a defense of its legitimacy by the speaker who originally produced it this excerpt is drawn from a discussion of affirmative actionrelated racial quotas in the selection of south african sports teams and the caller in this case is arguing in favor of such quotas excerpt in making his argument in favor of quotas the caller suggests that white people if they are not forced to give they will not give you anything a claim that is potentially hearable as a stereotype of the category white people it is important to note however that in producing this claim the caller twice notes that it is based on his experience in particular emphasizing the word my in each case in addition the second time he invokes his own experience the caller displays regret about his experiences through his use of the word unfortunately the insertion of this word marks the callers care in designing his utterance such that he interrupts its progressivity in order to display the stance the inserted word indicates the caller thus circumscribes the degree of generality of his claim about white people by displaying that it is based on his own experience as well as mitigating it by expressing regret thereby apparently designing the claim in such a way as to address its potential vulnerability to being treated as a stereotype and therefore as objectionable despite the callers careful design of his utterance however the host responds by comparing him to a previous caller from the same day who had expressed a stereotype linking black people to criminality and had been roundly condemned for doing so the host then goes on to specify the basis for his objection and his comparison of this caller to the prior caller stating that the caller is giving a blanket statement in this way the host treats the generality of the callers statement as the basis for his objection to it thereby producing his sanctioning of the caller as a response to an overgeneralized and therefore inaccurate link between a category and an attribute in response to the hosts sanctioning the caller immediately disagrees initially speaking several times in overlap with the host to negate what he is saying and then claiming that he will explain and substantiate the claim to which the host has objected he then goes on to dispute the hosts claim that he had made a general statement before reiterating his earlier framing of his claim in terms of his personal experiences the caller thereby challenges the hosts claim that he has in fact produced a blanket or general statement but at the same time tacitly aligns with the implication that giving a blanket statement would be an objectionable thing to do at just the point at which the host could recognize the callers appeal to his own experiences as a basis for his earlier claim the host speaks in overlap with the caller and marks his acceptance of what the caller is saying as the caller goes on to repeat his claim about white people the host displays his understanding and acceptance of the callers point and repeats his display of acceptance several more times the host thereby aligns with the callers claim of his personal experience as a basis for the circumscribed accuracy of his claims and in doing so effectively withdraws his sanctioning of the caller converting his prior treatment of the callers claim as morally objectionable to a new treatment of it as acceptable this excerpt thus demonstrates that the moral status of possible expressions of stereotypes is subject to momentbymoment negotiation and contestation with personal experience being collaboratively produced as one potential basis for defending the accuracy of a claim this use of personal experience as a resource in this way is consistent with sacks classic insights on the ways in which speakers are normatively treated as having a privileged entitlement to their experiences such that disputing the accuracy of a claim grounded in an individuals experiences would involve violating their takenforgranted ownership of the experiences this combination of participants orientations both to the accuracy of possible expressions of stereotypes as well as to the privileging of personal experience can also be seen in excerpt 4 in which the host strongly aligns with a possibly stereotypical claim a caller has made and has treated as potentially morally problematic in the process of producing this excerpt is from a discussion of crossracial adoption which the host has advocated throughout the show with this caller contributing to the discussion by describing her experiences of adopting crossracially having been congratulated by the host for having the chutzpah to go out there and adopt a kid the caller elaborates her description of her experience in this regard and produces a possible stereotype linking both white people and coloured people 3 people with looking at her funny on the basis of her having a child of a different racial category in claiming that it is not white people who have responded to her in this way the caller implies an expectation that people of this category would ordinarily be expected behave in such a way thereby providing a basis for their failure to do so being remarkable discussion of rules of irrelevance conversely by claiming that it is instead coloured people who have produced these responses the caller could be heard as producing a new stereotype linking such behavior with this second racial category as in excerpt 3 the caller produces these claims as reports of her personal experiences rather than as behavioral attributions applying more generally to all or most members of these categories however she nonetheless treats the claims as potentially delicate or problematic as shown by the laughter particles and smile voice indicated respectively by the hs in parentheses and the symbols her cutoff and restart on the word its just prior to her production of the first racial category term may also indicate an orientation to delicacy associated with mentioning this category although it may instead have been occasioned by the overlapping talk produced by the host just prior to this despite this orientation to the potential sanctionability of her claims on the part of the caller the host in this case immediately agrees with the caller with his emphasized i know treating the commonsense links she has drawn as being consistent with his own experiences and therefore accurate the host then follows up by stating that there is lotsa work to be done there still which seems to be a suggestion of the remedial action required to address a problem with the category of people that the caller and he have referred to despite the generalized and potentially hearably stereotypical nature of this suggestion neither the host nor the caller treats it as potentially objectionable as well as providing further evidence for participants orientations to the privileging of experiencebased claims that may otherwise be heard as stereotypical generalizations it is also potentially noteworthy that in this case the host is widely known to his audience as a member of the same racial category coloured referred to in this exchange as such his claims of knowledge of the behavior of people of this category may be implicitly grounded not just in his experiences with members of the category but in his status as a comember of the category in contrast to the caller who began the call by selfidentifying as white and whose orientation to the delicacy of the claims she was making was marked in contrast to the absence of any evidence of such an orientation on the hosts part the host may thus be orienting to a categorybased entitlement to produce selfstereotypes ie stereotypes in which the producer is a member of the same category implicated in the stereotype 4 excerpt 5 demonstrates a more explicit instance of this type of orientation to selfstereotyping as a caller works to display his selfidentification with the racial category implicated in a possible stereotype he is expressing this excerpt is from a discussion of a wave of xenophobic violence that was occurring across south africa at the time with the caller first complaining about the lack of action to prevent the violence taken by leaders in the country before criticizing those who he treats as primarily culpable for perpetrating it in shifting the focus of his criticism from leadership to the perpetrators of the violence the caller specifically blames a lack of education especially forfor black south africans for the problem thereby producing a possible stereotype of black south africans as uneducated then after producing this possibly complete formulation of those he is singling out for blame the caller quickly adds the collective pronoun us to the formulation thereby claiming membership in the category black south africans the caller thus performs additional work to retrospectively include himself in the category about which he has produced a possible stereotype having not done so initially then as he continues his criticism the caller uses the pronoun we on several further occasions thereby continuing his display of comembership in the category he is criticizing in response the host initially minimally aligns with the caller before displaying agreement followed by an aligning account for the problem the caller has identified that implements another possible stereotype linking the category black south africans to the attribute of poverty in his claim that our stomachs are empty in producing this response the host uses the pronouns we and our in ways that similarly to the callers use of pronouns display his comembership in the category black south africans it noteworthy that in producing these possible stereotypes both the caller and the host treat their actions as potentially delicate this can be seen in the brief pause and restarts produced by the caller just prior to his formulation of black south africans and in the hosts numerous restarts prior to agreeing with the callers claim that we are not educated this provides further evidence for the possibility that speakers selfinclusion in a category about which they are expressing a negative possible stereotype may both display an orientation to and serve as a way of managing the potentially objectionable nature of their actions the final excerpt 5 below indicates another way in the relevance of the accuracy and accompanying moral accountability of stereotypes can potentially be relaxed or bypassed namely through their use as a resource for humor or joking prior to the exchange shown in the excerpt the host and caller have discussed the degree of racial inequality in south africa leading the caller to question how such inequalities can after fourteen years of democracy still exist in response the host invokes a possible stereotype of white people as wealthy as a resource for a jokingly proposed short term solution that the caller could find a white girlfriend this proposed solution by the host is underpinned by his designedly more serious discussion of the importance of affirmative action policies and prevailing distributions of money and power while he does not explicitly mention race in this discussion his mention of affirmative action along with the prior discussion of ongoing racial inequality provides for a hearing of his claims about money and power as referring specially to racialized distributions this in turn serves as the basis for the host to imply that the caller occupies a disadvantaged position that could be improved sharing in the wealth of a white girlfriend this joking suggestion by the host initially results in some interactional trouble as the caller initiates repair in line 14 before displaying his appreciation of the joke by laughing just after the host begins to repeat it the interactional trouble can thus be seen as a transient problem in hearing rather than for example a result of the caller treating the hosts joking use of a possible stereotype as objectionable the caller thus collaborates with the host in treating the racewealth link as unproblematically humorous rather than morally accountable discussion and conclusions in this paper i have considered some of the ways in which the moral status of stereotypes and stereotyping has been the subject of implicit and explicit concern within the social psychological literature and has shaped the practices adopted in the production of social psychological research in contrast to dominant social psychological approaches to research on stereotypes which attempt to access their core cognitive essence independently from any interactional context i have conducted a detailed examination of the interactional trajectories associated with the production of stereotypes in the naturally occurring interactional exchanges in which they occur in particular my analysis has contributed to the literature focusing on the management of the moral accountability of stereotyping in everyday interactions by demonstrating participants systematic treatment of the accuracy of possible stereotypes as a primary basis for their status as morally objectionable i have also demonstrated some apparent bases upon which this centrality of accuracy could be relaxed or set aside by participants including stereotypes grounded in personal experiences selfstereotypes and humorous uses of stereotypes these findings demonstrate some ways in which concepts such as accuracy and indeed stereotypes are participantadministered that is it is participants themselves who decide whether a possible instance of stereotyping should be properly treated as such and whether an expressed stereotype is sufficiently inaccurate or overgeneralized to warrant resistance or sanctioning the participants can thus be seen to be navigating in situ the question of whether their own other others talk can be considered prejudicial or more specifically in these cases racist and if so whether and how it can or should be challenged as the data demonstrate these decisions involve contingent interactional negotiation whether a possible instance of stereotyping is treated as morally objectionable is shaped by the details and context of its delivery and this treatment is subject to negotiation contestation and revision and is sensitive to factors such as the treatment of a stereotype as being grounded in personal experience its status as a selfor otherstereotype and the action that the stereotype is being used to implement this shows the highly contextsensitive and interactional nature of stereotyping and the importance of a momentbymoment examination of how it unfolds interactionally in order to better understand what stereotyping is for the people doing it and responding to it and how they manage the contingencies associated with it this contingent and situated interactional character of stereotypes demonstrated by the analysis also provides further support for the abovementioned discursive psychological critiques of social psychological approaches to stereotypes that strip away the social contexts of their expression that is it is evident from the data i have examined that for the participants who produce and respond to them stereotypes are not only cognitive or individuallylocated phenomena but are also interactional resources that speakers can deploy in producing everyday social actions as such it is evident that stereotyping is not the primary thing that the speakers in these interactions have set out to do rather it is something they may do in the service of accomplishing whatever their interactional business at particular moments happens to be while at the same time being subject to the normative moral constraints associated with everyday actions more generally thus in contrast to its treatment in some social psychological research as a contaminating factor to be mitigated or circumvented through methodological innovations the moral accountability associated with stereotypes and stereotyping is observable as a fundamental and constitutive feature of the phenomena at hand the support of national research foundation incentive funding for rated researchers towards this researchactivity is hereby acknowledged opinions expressed and conclusions arrived at are those of the author and are not necessarily to be attributed to the nrf notes 1 for further discussion of potential shortcomings of the social cognitive approach and of implicit measurement techniques in particular see eg billig durrheim and tetlock and arkes 2 also see whitehead for further analysis of this excerpt 3 the term coloured was used during the apartheid era to categorize mixedrace people and also it became highly politically contested during the later years of apartheid and in the postapartheid period it remains widely in use in everyday south african talk 4 this type of orientation to entitlement to action based on self versus other considerations has been observed in a number of domains including conversational repair knowledge and experience and intersections between social categories and everyday actions such as complaints 5 also see analysis of this excerpt in whitehead funding authors note earlier versions of the article were presented at the 2011 international society for political psychology conference in istanbul turkey and at the 2015 annual meeting of the american sociological association in chicago illinois declaration of conflicting interests the author declared no potential conflicts of interests with respect to the authorship andor publication of this article terracciano a abdelkhalek a m ádám n adamovová l ahn ck ahn hn mccrae r r national character does not reflect mean personality trait levels in 49 cultures science 310 96100 language and social psychology 34 374389 whitehead k a stokoe e producing and responding to isms in interaction language and social psychology 34 368373 wilkinson s kitzinger c constructing identities a feminist conversation analytic approach to positioning in action in r harre f moghaddam the journal of author biography kevin whitehead is an associate professor in the department of psychology at the university of the witwatersrand johannesburg his research employs an ethnomethodological conversation analytic approach to examine race and other categorical forms of social organization and inequality focusing on ways in which racial and other social categories are used reproduced and resisted in talkininteraction

this paper addresses some ways in which stereotypes and stereotyping are treated as morally accountable by social psychologists their research participants and participants in everyday interactions i focus in particular on closely examining some deployments and responses to stereotypes in everyday interactions by applying conversation analytic and discursive psychological approaches to recorded interactions from radio callin shows my analysis considers the different interactional trajectories that follow the production of possible racial stereotypes demonstrating how participants treat their inaccuracy as a central basis for the production of challenges and moral sanctioning in response to their deployment in addition the analysis demonstrates some cases in which apparent stereotypes are accepted or aligned with including those grounded in personal experiences selfstereotypes and humorous uses of stereotypes i conclude by considering the implications of attending to the socialmoral contexts in which stereotypes are produced and the participantadministered accountability associated with these contexts

introduction the era of digital natives is a term used for generations that grew up with the digital world and became part of the rapid progress of social networks genz is part of the generation in the digital natives era who spend their time using the internet and interacting through social media experiencing the rapid sophistication of technology that offers a lot of convenience and efficiency consumptive behavior is part of life in the digital navies era in genz which is to fulfill pleasure and satisfaction consumptive behavior is a hedonistic behavior that prioritizes happiness over needs according to ancok wasteful behavior is buying products that someone does without considering aspects of needs but buying products that the individual does not need consumptive behavior can be interpreted as the tendency of individuals to consume a product excessively without making various considerations where it is more concerned with pleasure and prioritization than needs generation z is the generation that was born between the mid1990s and early 2010s they are the first generation to grow up in the digital age and they have a unique set of values and behaviors that have shaped their consumer habits one of the most notable aspects of genzs consumer behavior is their focus on issn 24433810issn 20881134website email identity genz consumers are more likely to purchase products and services that align with their personal values and beliefs they are also more likely to use social media to express themselves and connect with others who share their interests data released by the we are social survey in 2021 states that indonesia is ranked first as the highest country for ecommerce users globally around 881 of internet users in indonesia use ecommerce services to buy a particular product online shopping through ecommerce is carried out in several applications namely shopee lazada tokopedia zalora tiktokshop instagram and other applications that always offer convenience this application has optional features that buyers can adjust to their desired product such as size product description original product photos and product details this is one of the conveniences offered by the modern era that can encourage the formation of consumptive behavior in individuals ecommerce is one of the places that quickly sells viral fashion products to meet the general publics fashion needs data in 2022 shows that fashion products are the most popular products throughout the year on the shopee application the populix survey in 2020 revealed that most online shopping activities are carried out by groups of people aged 1828 years with an average of rp50000rp500000 in general students basic needs are buying books and learning equipment to facilitate learning however there are aspects of the lifestyle that students want to fulfill so they encourage them to adopt a consumptive lifestyle one of which is by buying goods online outside of needs through ecommerce the problem is that the items purchased tend not to be used and are not too important only used to show a luxurious identity and impress others well in forming an identity individuals tend to provide symbols intended for people to include personal branding following what is expected referring to haroen personal branding is formed to create a positive perception and highlight selfcharacter built with the personality abilities and values that a person adheres to in forming their identity individuals tend to buy imageaware products given by the product itself personal branding is an exciting phenomenon to discuss in the era of digital natives where more and more people are aware of the importance of building an image in the eyes of the general public personal branding is forming an identity in society towards aspects of oneself to create a positive impression ganiem explains that personal branding is how a person markets himself to others systematically personal branding can be formed through how to dress how to dress is one of the crucial indicators in creating personal branding a person will develop personal branding through how one dresses by giving an image of certain impressions and messages channeled through the outfits and clothes used the trend of how to dress also continues to develop in line with the change of time good personal branding encourages individuals constantly to monitor the development of existing fashion trends selfidentity can be formed through social media by showing the best posts to friends so that a good selfidentity is formed on social media social media is a means users use to carry out various activities and various information through images text video and audio instagram is one of the most popular social media known by many people some features can be used on instagram to share photos and videos with fellow followers and other users the use of social media in forming a selfidentity has rapid development along with the increasing social media users social networking sites are used more widely as a medium for forming personal branding the news study lies in the agil concept by talcott parsons which the author uses to interpret the consumptive lifestyle phenomenon in genz this study aims to describe the social phenomenon happening to genz especially students related to consumptive behavior carried out to form personal branding through online shopping activities through the agil concept the research will explain the consumptive phenomenon in forming identity through four main functions adaptation goal attainment integration and latency tapscott states that if we can understand the generation close to the internet we can predict the future so it is essential to study the phenomenon of consumptive behavior in creating personal branding to address it correctly b method this research uses descriptive qualitative methods interviews observations field notes and researcher observations carry out data collection techniques is analyzed using the concept of a g i l by talcott parsons the research aims to describe life in the digital navies era regarding the phenomenon of consumptive behavior and personal branding that they have experienced and have seen students are a generation familiar with technology so they are more active in using social networks and become most online shop users for this reason the author uses students as the correct informants to explain the subject matter and achieve research goals students who become informants are students from various universities such as the universitas sumatera utara 3 students north sumatra state islamic university with one student and prima indonesia university with one student the five informants in this study were selected based on several criteria genz active and consistent ecommerce users and active social media users these five informants have met the authors criteria and can provide answers to the topics raised by the author c literature study an important topic in this study is the phenomenon of personal branding formation that underlies a persons consumptive behavior this research is based on the current reality and is supported by several theories and previous studies the theory used in the study is the concept of agil by talcott parsons talcott parsons was one of the same followers of the functional structural school as comte durkheim and spencer parsons views social change by focusing on the nature of the social structure that will lead to social evolution parsons argues that the study of social change must first begin with the study of social structure more profoundly parsons view refers to the dynamics within a social system as part of the social structure parsons explained that structural changes that occur in society can be influenced by several aspects one of which is trends changes in society are covered in several stages commonly referred to as the agil concept these four functions are used to maintain a system a adaptation this function emphasizes the importance of selfadjustment to the environment and its needs this function is used to explain student behavior patterns in the digital native era genz consumers are welladapted to the digital age they are more likely to use social media to research products and services and they are more likely to be influenced by online reviews this adaptation to the digital age has led to a more consumptive lifestyle among genz consumers genz consumers are more likely to be exposed to new products and services through social media and more likely to be influenced to purchase those products and services b goal attainment this function emphasizes the importance of a system in defining and achieving common goals this function is used to explain the goals that students want to achieve in consumptive behavior genz consumers are more likely to be motivated by selfexpression and personal fulfillment than by financial gain they are also more likely to be concerned about sustainability and social responsibility this focus on selfexpression and personal fulfillment has led to a more consumptive lifestyle among genz consumers genz consumers are more likely to spend money on experiences and products that make them feel good about themselves and their identities c integration this function emphasizes the importance of balance in managing relationships between other functions namely adaptation goal attainment and latency this function is used to identify aspects that link consumptive behavior with the formation of personal branding genz consumers are more likely to be connected to their peers through social media they are also more likely to be involved in social causes this integration with their peers and involvement in social causes has led to a more consumptive lifestyle among genz consumers genz consumers are more likely to be influenced by their peers to purchase products and services and are more likely to be motivated to purchase products and services that support the social causes they care about d latency this function emphasizes the importance of pattern maintenance through maintaining existing systems and improving individual motivation and cultural patterns this function is used to explain the behavior patterns carried out by students in maintaining their consumptive behavior genz consumers are more likely to be open to new experiences and products they are also more likely to be influenced by trends and fads this openness to new experiences and products has led genz consumers to a more consumptive lifestyle genz consumers are more likely to experiment with new products and services and are more likely to be influenced to purchase trendy products and services according to parsons these four functions are imperative or prerequisites for the continuity of the social system the entire living system must meet some particular needs or functions there are two essential points included in functional needs the internal system needs or system needs when related to the environment and something related to the target system or goals and means that need to be done to achieve these goals the focus on identity is a crucial driver of genzs consumer behavior genz consumers are more likely to purchase products and services that reflect their unique identities they are also more likely to use social media to express themselves and connect with others who share their interests this focus on identity is likely due to some factors genz consumers are growing up in a world constantly bombarded with messages about who they should be they are also more likely to be exposed to different cultures and perspectives through social media as a result they are more likely to question the traditional definitions of identity the focus on identity has some implications for businesses businesses must understand genz consumers unique values and beliefs to target them effectively they also need to create products and services that reflect the diversity of genz identities this research is supported by several previous studies on consumptive behavior shaping personal branding and discussing the digital natives era in a study by salam entitled personal branding digital natives in the era of new media communication in jurmal becoos in 2020 it can be concluded that personal branding that a person tries to form on his social media can create an impression of selfcharacter to his followers also supported by the research of rahayu et al with the title consumptive behavior as an impact of the existence of online shop among sociology students 2019 state university of malang in the journal integration innovative harmony of social sciences in 2021 it was concluded that in consumptive behavior people tend to buy an item based on desires not needs d results and discussion this research found the reality that students are motivated to buy goods in ecommerce because it is more accessible practical and affordable students prefer buying clothes and fashion items in ecommerce rather than offline stores this is because there are quite a lot of promos offered on online shopping applications one is the free shipping promo that shopee tiktokshop lazada and tokopedia offer shopee is one of the most visited online shopping applications with 161 million people tokopedia with 106 million people and lazada with 70 million people one of the driving factors for students to use this online shopping application is that it always provides shipping promos and massive monthly discounts not infrequently students are encouraged to buy a product because it is on promo without thinking about the usefulness and function of the product in the future the product bundling promo buy 2 only rp 150000 encourages students to buy products that will not necessarily be used another motivation encourages students to behave consumptively because they are tempted by marketing strategies or product advertisements on social media social media platforms have become powerful marketing tools for brands to reach their target audiences including students these platforms offer a variety of ways for brands to advertise their products such as through sponsored posts influencer partnerships and targeted ads large platforms such as tiktok and instagram are marketing platforms for brands to introduce their products marketing strategies on instagram usually use the services of artists celebrities and influencers to attract followers to buy a product marketing strategies on tiktok are usually carried out by content creators and ordinary users who promote a product with the term honest review however honest content here is only part of a brands marketing strategy by only showing the positive side of a product marketing strategies on social media are designed to pique consumers interest and curiosity and students are no exception when students see their favorite celebrities influencers and content creators promoting a product they are more likely to be interested in learning more about it in addition to the marketing strategies mentioned above social media makes it easier for students to purchase products impulsively students can buy products from their smartphones or computers without leaving their homes with just a few clicks this convenience can make it difficult for students to resist the temptation to spend money on things they may not need or want social media plays a significant role in encouraging students to behave consumptively students are bombarded with daily marketing messages on social media which can effectively persuade them to buy products it is important for students to be aware of the marketing strategies that brands use on social media and to be critical of the content they see changes in the structure of genz behavior in the digital natives age can be seen more broadly through comprehensive stages parsons introduced these stages in the agil concept adaptation goal attainment integration and latency this table is expected to provide a clear picture of the changes table 1 agil concept agil explanation adaptation online shopping activities on ecommerce and forming selfidentity on social media are forms of genzs adaptation to technological developments and the digital world in the digital natives era which always offers convenience and efficiency in every activity goal attainment genz aims to consume fashion items to form their branding on social media personal branding is formed to provide a positive image and selfidentity to others integration fashion trends unite genz in buying an item that is going viral latency genz normalizes their consumptive behavior to keep up with trends and lifestyles this can be seen from students awareness of their consumptive behavior but still want to meet their personal branding needs source author analysis parsons explained that the adaptation function is seen through a behavioral system the development of technology and internet networks has formed a new pattern of alldigital life by offering convenience and efficiency in the era of digital natives there is a change in behavior patterns carried out by the younger generation in shopping activities namely the change from direct shopping to shopping through online applications media continues to evolve to form new media such as social media which has changed the direction of communication to be more active the digital natives era is where many active social media users use social media as a medium of communication information media online shopping and entertainment personal branding is one of the highlights of the widespread use of social media personal branding is forming a positive impression conveyed by individuals through certain symbols according to mcnally and speak there are three indicators in forming personal branding individual competence or ability style and personal branding standards style or style can form a unique impression on individuals in the perception of others individuals tend to follow style trends to give an uptodate impression to their followers on social media this will then give birth to excessive consumptive behavior in individuals forming the desired personal brand agil theorys adaptation function is evident in how genz students have adapted their shopping behavior to the digital age in the past students would typically go to physical stores to shop for clothes students can shop from the comfort of their own homes and have their purchases delivered to their door the rise of social media has also played a role in shaping the consumer behavior of genz students social media platforms such as instagram and tiktok are popular among genz students these platforms allow students to share their fashion sense and lifestyle with others students also use social media to follow fashion influencers and learn about the latest trends the desire to create a positive personal brand on social media can lead to excessive consumption among genz students students may feel pressured to buy new clothes and fashion items to keep up with the latest trends this can lead to financial problems and a cycle of debt parsons explains that the goal achievement function is a function of the personality system personal branding is consistent in the form of an image and identity that you want to show to others the study found that 4 out of 5 informants stated the importance of image formed through style or dress a products image can give others an impression such as a feminine stylish and charismatic impression students tend to buy clothes and fashion items that are tailored to the image they want to show students prefer to buy these clothes and fashion items through ecommerce not infrequently these items are only for one or two uses not even used at all students form their branding through personal social media such as instagram the instagram story feature and instagram posts show the best image that individuals want to form no wonder most also pay attention to how to dress to form their impression the personal branding students want to form is a positive elegant and calm image through their outfits that way students must pay attention to the style of their clothes through a combination of suitable colors and a balanced combination of fashion items all will be returned to the image that each student wants to form another important aspect in forming personal branding through how to dress is to pay attention to the cleanliness and neatness of clothes students even tend to be selective in choosing the posts they will upload on social media this emphasizes the importance of personal branding for students the third function in talcott parsons agil concept is integration this research shows that fashion trends affect student motivation in shopping for clothes and other fashion items there is an encouragement for students to fulfill the desire to follow the style that is becoming a trend on various platforms so that they can finally buy the product one of them is the trend of dressing all pink when the barbie movie was released last july the research informants stated that they were interested in buying various fashion items that were all pink the fourth function in the agil concept by talcott parsons is latency this study found that students are aware of their consumptive behavior they also realize that their clothes and other products are useless and unused for a long time this is because fashion trends will continually change over time however the reason for wanting to follow the trend and the need to form personal branding encourages them to continue buying the product for students appearance can create an impression that will shape their branding in the eyes of others glock states that consumptive behavior carried out by individuals is aimed at certain desires one of which is the desire to be appreciated through the formation of personal branding students feel more confident when meeting people out there there are positive impacts and negative impacts of forming personal branding the positive impact is that the opportunity to get a job becomes greater this is based on results showing that 70 of companies research prospective employees through social media data released by hca canada states that 28 of company managers search for job candidates through social media to find information with good personal branding on social media someone has more opportunities to be glimpsed by companies in finding work the negative impact of forming personal branding lies in the excessive tendency of individuals to follow their social group the result will only harm itself because of the coercion to continue to meet the needs in the formation of personal branding always wanting to follow the trend to form a luxurious image will only encourage individuals to be more consumptive in addition extravagance will become a bad habit that persists in the individual in some situations the informant said they had to use their savings to buy discounted clothes or bundling promos in a wider range this personal branding will cause social jealousy that is formed because of our perspective in seeing something that cannot be obtained based on the results of the research conducted it can be seen that consumptive behavior has become part of genzs daily life in the digital natives era consumptive behavior has been normalized in online shopping activities genz tends to use online shopping apps to buy fashion and beauty products some online shopping applications often used include shopee tokopedia tiktokshop lazada and zalora the results showed that fashion is one of the crucial indicators in shaping their branding on social media the motivation to buy an item changes from meeting a need to fulfilling satisfaction brands brands and trends are the reasons genz consumes goods excessively genz wants to make their branding image more elegant have positive vibes and seem calm in a conscious state genz normalizes online shopping consumptive behavior to form a special image of itself through style in the form of fashion or appearance on social media e conclusion the results show that personal branding is important for students social media is a place for students to show their impression image and identity to others through instagram story posts and posts on their personal accounts one of the indicators needed to form a personal brand is how you dress how to dress contains aspects of combining outfit colors and the balance of fashion items used through the way students dress students want to form a positive charismatic and calm identity this causes students to tend to do consumptive behavior by buying clothes and fashion items on ecommerce to form their personal branding on social media agil theory has explained the phenomenon of consumer behavior in meeting personal branding needs in the era of digital natives through comprehensive stages 1 adaptation this function explains that the era of digital natives has created a new pattern of alldigital behavior by offering convenience and efficiency in line with the rampant development of social media and online shopping applications online shopping activities and identity formation on social media by students are a form of student adaptation in following the existing developments in the digital natives era 2 goal attainment this function explains that the goal that students want to achieve in buying fashion products is to form their identity on social media in order to form a good impression and image 3 integration this function explains that fashion trends have linked students motivation in buying products with the image they want to highlight as selfidentity the last function 4 latency explains that there is awareness made by students regarding their consumptive behavior in shopping causing normalized behavior patterns f acknowledgment this article especially thanks the parties who were positively involved in the research and writing of the article from the beginning to the end of the completion of the writing first the authors would like to thank the five informants who helped provide the information needed in the research second thank you to sister nahwa zainab marpaung and sister rowiyah asengbaramae as colleagues in research and article writing so that the research and writing this article can be completed properly

the era of digital natives has offered many conveniences including social media and ecommerce this use contributes to personal branding resulting in the creation of selfidentity this study aims to describe the social reality of genz in performing consumptive behavior for personal identity in the digital natives era with the agil concept this research uses descriptive qualitative methods data collection techniques used are interviews and observations there were five informants in medan the results showed that genzs consumptive behavior in online shopping in the digital natives era was influenced by the demands of forming personal branding through fashion which was becoming a trend on social media some informants normalize their consumptive behavior to follow directions and develop personal branding according to the theory of parsons agil this phenomenon results from social change related to consumption behavior this study concludes that the need to form personal branding has manipulated students awareness of wasteful behavior

grandparent and grandchild but no parent referred to here as a grandfamily some studies document the characteristics strengths and challenges of grandfamilies missing however is an analysis of how the characteristics and wellbeing of those in grandfamilies including the nonresident parents compare to those in other families we provide a detailed comparison of how grandparent caregivers compare with the childs nonresident parents and with other parents of similar socioeconomic backgrounds and we examine the wellbeing of children in grandfamilies utilizing a wide range of highquality measures of child wellbeing from multiple reporters background characteristics and comparison of grandparents nonresident parents and grandchildren an extensive literature studies grandfamilies given the nature of this brief report we are not able to fully review this literature here but we highlight some key studies particularly relevant to our research questions especially well documented are the characteristics and challenges faced by grandparents raising their grandchildren research using us census data found that 49 of children in grandfamilies live with both grandparents 46 with just a grandmother and 5 with just a grandfather overall compared to noncustodial grandparents those raising their grandchildren generally have poorer physical and mental health and more stress and grandfamilies are poorer economically than other households with children at the same time grandfamilies exhibit numerous strengths including a very warm bond between grandparent and grandchild an increased sense of purpose on the part of the grandparent and a wisdom and maturity that comes with parenting for a second time most prior research studying the wellbeing of children in grandfamilies has compared grandfamily childrens wellbeing to that of us children generally finding that grandfamily children had elevated behavior problems and poorer academic outcomes a smaller set of studies have compared grandfamily children to other similarly economically disadvantaged children finding elevated behavior problems and lower levels of school engagement and one study showed no differences when compared to those in traditional foster care research has found that children in grandfamilies fare better we consider a wider range of child wellbeing measures from multiple reporters systematically comparing grandfamily children to similarly disadvantaged urban children less well understood are the characteristics of nonresident mothers and nonresident fathers in grandfamilies although research documents that many nonresident parents have ongoing regular contact with their children virtually nothing is known about the characteristics of nonresident mothers and fathers of children in grandfamilies this study fills that gap a key issue when examining the wellbeing of grandfamilies is determining the appropriate group to whom such families should be compared given evidence that grandfamilies often face financial health and emotional challenges comparing those in grandfamilies to those in average families is problematic in that it does not allow for disentangling what is unique about the grandfamily living arrangement from the factors associated with disadvantage this study systematically compares the characteristics of those in grandfamilies to several key groups of interestthe average urban mother the average urban father the nonresident parents with whom the children previously resided and other disadvantaged urban children making such comparisons allows us to better understand how a childs grandfamily living arrangement compares to other family contexts method data data came from the fragile families and child wellbeing study a longitudinal birthcohort study of nearly 5000 births in large us cities sampled between 1998 and 2000 nonmarital births were oversampled resulting in a relatively economically disadvantaged sample mothers and fathers were interviewed soon after the birth of the focal child and followup interviews were conducted when the child was approximately 1 3 5 and 9 years old we mainly utilized the 9yearold data gathered when the average child was in third grade although some descriptive information was drawn from earlier waves we used 9yearold data from the nonparental caregiver survey the primary caregiver survey the biological mother survey the biological father survey the child survey and the teacher survey we focused on the 9yearold data because this wave represents the first survey with interviews of nonparental primary caregivers as well as nonresident mothers and fathers and the children themselves our analyses included 84 grandparents raising their grandchildren with no parent in the household our analyses also included information on 79 children being raised by their grandparents in the interest of maximizing cases we retained all 84 grandparent responses additional analyses restricting the sample of grandparents to those whose grandchildren responded to the survey yielded similar results our analyses also included information on 47 nonresident mothers and 34 nonresident fathers whose child was being raised by a grandparent data were missing for 37 nonresident mothers and 50 nonresident fathers analyses of the 25 nondeceased and nonincarcerated mothers missing data in year 9 show that they had very similar characteristics as those who were interviewed in contrast the 29 missing fathers were somewhat different from those who were surveyed they were more likely to have been single at the birth of the child to be of hispanic raceethnicity and to be an immigrant we consider the implications of this differential attrition in the conclusion we compared those in grandfamily households to individuals in other types of families to perform meaningful contrasts we restricted our comparison groups to be included in the biological mother or the child comparison group both the mother and child had to complete the survey yielding 3098 nongrandfamily mother and child responses for the biological father comparison group we retained only cases in which the child had also responded yielding 2174 cases similarly for the teacher survey we retained cases in which the teacher and child responded 52 children who lived in a grandfamily and 2064 children who lived with a mother primary caregiver measures grandfamiliesgrandfamilies were identified as households including the focal child at least one grandparent and no parents a variable indicating whether the child lived with a maternal or paternal grandparent was constructed as well as one identifying whether the child lived with just the grandmother just the grandfather or both household structure more broadly was constructed to include spouses and partners of the grandparent the grandparents own parents the childs aunts or uncles cousins other relatives or nonkin we also measured number of people in the household and number of siblings of the focal child living in the household we calculated the years that the child had lived with the grandparent using the current interview date and the date when the child came to live with the grandparent demographic characteristicswe measured a number of demographic characteristics of the grandparent respondent the biological mother and the biological father including relationship status age at childs birth education nativity laborforce participation health status depression an indicator of poverty and material hardship frequency of visitation was asked of the grandparent respondent about both mothers and fathers and of the biological mother and the biological father themselves for mothers and fathers we included marital status at the birth of the child raceethnicity whether drugs andor alcohol had interfered with their life the number of biological children currently living with them and the distance from their house to their parents house these variables were not available for the grandparent caregiver respondents child wellbeingchild health was assessed using the overall health status measure reported by the caregiver about the focal child indicators for obesity were constructed using interviewer gathered data we categorized children with a bmi at or above the 95th percentile as obese following guidelines from the centers for disease control and using percentiles calculated from data from their 2000 growth charts adjusted for childs age in months gender height and weight primary caregivers also reported whether the child had any health conditions including attention deficithyperactivity disorder a developmental delay or mental retardation autism or an other health problem such as a heart condition deafness or a speech problem most of the child cognitive socioemotional and school wellbeing measures included scales or indexes each index was standardized to have a mean of 0 and a standard deviation of 1 so that higher scores reflect more of the outcome child cognitive ability was assessed using the peabody picture vocabulary test the woodcockjohnson passage comprehension test 9 and applied problems test 10 and the weschler intelligence scale for childrendigit span subset teacher reports of childrens academic performance in social studies language literacy and math were reported for a subset of children child socioemotional wellbeing was reported by primary caregivers using the 618 child behavior checklist capturing both externalizing and internalizing behavior children also reported on their own externalizing and internalizing behaviors and emotions using the self description questionnaire teachers reported on childrens behavior using the social skills rating system and the conners teacher rating scale the ssrs included externalizing internalizing cooperation assertion and selfcontrol subscales teachers also reported on approaches to learning a scale that assessed childrens attention persistence and interest in learning the conners teaching rating scale assessed oppositional behaviors cognitive problems or inattention hyperactivity and attention deficithyperactivity disorders some measures of school wellbeing were collected from the child connectedness at school included measures of inclusiveness closeness happiness and safety peer bullying included four items task completion assessed children on five items related to staying on task and followthrough delinquency was reported by the child and comprised 15 items related to vandalism truancy or theft last primary caregivers were asked whether the child had ever repeated a grade in school because the study was descriptive in nature we reported bivariate descriptive statistics when applicable ttests were run to test for statistically significant differences across groups results grandfamily households table 1 provides descriptive information on the grandfamilies in our sample almost threequarters of grandfamilies involved maternal grandparents most children lived with a grandmother although about onethird lived with both grandparents nearly half of children also lived with an aunt or uncle and many lived with cousins nonkin and great grandparents more than half of children also lived with one or more of their own siblings resulting in an average household size of nearly five people table 1 documents the length of time the focal child had lived with the grandparent on average children in this sample who were approximately 95 years old had lived with a grandparent for 57 years or 60 of their lives 11 had lived with a grandparent for less than a year and 42 had always lived with their grandparent most grandparents expected their grandchild to live with them until they reached adulthood characteristics of grandparents nonresident parents and comparison parents table 2 compares characteristics of grandparents raising their grandchildren to those of several groups first grandparents raising grandchildren are compared to nonresident mothers of children in grandfamilies with results indicating that in general grandparents were more advantaged than the childrens mothers grandparents raising their grandchildren were twice as likely as the childrens nonresident mothers to be married significantly less likely to have dropped out of high school and more likely to be college educated grandparents were also much less likely to be unemployed poverty and hardship rates were significantly lower among grandfamilies than among nonresident mothers finally nonresident mothers were significantly less likely to be immigrants than grandparents however this may be driven by selection as immigrant parents may not have their own parents in the united states which makes it less possible to have their child live in a grandfamily next we examined how grandparents raising their grandchildren compare to residential fragilefamily mothers raising their own children few significant differences exist between the two groups grandparents were significantly more likely to be single and less likely to be cohabiting than resident mothers whereas both groups were married at similar rates education differences were small but grandparents were generally more educated than residential mothers grandparents were older than residential mothers and had significantly poorer health ratings but no other health differences were significant among grandparents in the labor force differences in employment were small thus it appears that grandparents raising grandchildren have very similar characteristics to residential urban mothers raising their own children comparing nonresident mothers to mothers who raising their own children shows that nonresident mothers were much more disadvantaged in terms of marital status age education employment health and substance use although by default all mothers living with their own children had children living with them more than half of the nonresident mothers had one or more other children living with them comparing fathers whose children were being raised by a grandparent to fathers whose children live with their mothers again reveals that nonresident parents of children in a grandfamily were more disadvantaged than other parents as was the case with the mothers 55 of nonresident fathers had other biological children living with them table 2 also compares reports of the frequency of visitation by nonresident mothers and fathers to their children in grandfamilies grandparents reported that both mothers and fathers visited an average of nine days a month nonresident mothers and fathers reported seeing their children even more frequentlyboth said they saw their child 12 days per month additional analyses showed that many nonresident mothers and fathers reported seeing their child every day yet a significant share did not see their child in the previous month only 2 of mothers and 15 of fathers did not see their child in the previous year wellbeing of children in grandfamilies table 3 compares the wellbeing of children in grandfamilies to that of children living with their mothers the only significant healthrelated difference between children in grandfamilies and those living with their mothers was the incidence of attention deficit disorderattention deficit hyperactivity disorder twentypercent of children in grandfamilies had been diagnosed by a doctor with addadhd compared to 11 of children living with their mothers more differences emerged when looking at cognitive and academic assessments compared to children living with their mothers children in grandfamilies generally had lower cognitive scores although only for the applied problems score was this difference significant teacher reports also show that children in grandfamilies had average language literacy and math grades that were significantly lower than children who lived with a parent looking at socioemotional development and behaviors caregivers reported significantly higher levels of externalizing behaviors among children in grandfamilies teachers reported that children in grandfamilies were significantly less cooperative displayed more oppositional behavior had more cognitive andor inattention problems and had lower scores on the approachestolearning scale than other children finally children in grandfamilies reported significantly lower task completion abilities they were also twice as likely to have repeated a grade and were significantly more likely to have engaged in delinquent activities than children living with their mothers in auxiliary analyses available in appendix a we investigated differences in parenting approaches comparing grandparents to resident mother households on measures of parenting activities and engagement in school monitoring physical and psychological aggression neglect and household routines we found few significant differences between the two types of households although grandparents were significantly less likely to know the childs friends and significantly more likely to eat meals together than typical residentmother households conclusion this study contributes to the understanding of grandfamilies in several ways it is the first study to use survey information gathered from all grandfamily members including mothers and fathers living outside of the household given that the vast majority of children in grandfamilies remain in contact with their nonresident parents obtaining information about these parents is crucial this study is also the first to systematically compare the characteristics of grandparents raising their grandchildren to multiple other key groupsurban mothers raising their own children urban fathers nonresident mothers and nonresident fathers last this study provides new insight into how children in grandfamilies fare on a wide range of measures of child wellbeing as compared to s several key findings emerge nonresident mothers and fathers are much more disadvantaged than both grandparent caregivers and other urban parents raising their own children this study is one of the first to be able to concretely document just how much better off grandparents are relative to the nonresident parents of the children they are raising grandparents have higher levels of human capital and significantly lower levels of poverty and hardship than do nonresident mothers and fathers this suggests that children in grandfamilies often enter a living arrangement with more economic advantages than the one they left behind we note that more than half of nonresident parents had biological children living with them at the time of the survey given their relative disadvantage compared to grandparent caregivers this is an area for future research in particular research that compares the wellbeing of children who are raised in a grandfamily with that of children who remain with a parent would help shed light on the implications of grandfamily living arrangements for child wellbeing another key finding is that grandparent caregivers have characteristics that are very similar to other urban parents some studies have shown that grandparent caregivers are disadvantaged relative to other grandparents in terms of their physical and mental health yet when compared with other economically disadvantaged parents we find that grandparents look quite similar and have comparable parenting practices certainly as compared with the us population of children those in grandfamilies are more disadvantaged but the relative disadvantage as compared with other lowincome households is not evident future research on grandparent caregivers should carefully consider the appropriate comparison group when drawing conclusions about the wellbeing of those in grandfamilies consistent with previous research we find that nonresident parents see their children frequentlytwo to three days a week on average this has implications for thinking about how social service agencies and social workers engage with these families programs targeting nonresident parents of children in grandfamilies will likely have spillover benefits for the children in grandfamilies as well given the high levels of need and interactions with these parents future research should consider the role of social service agencies in not only helping grandfamilies but also assisting nonresident parents in aiding children in grandfamilies the frequent interactions with nonresident parents observed here also points to the need to think about how to best serve children and grandparents while taking into consideration the parents as a potential actor in the household system research on nonresident fathers of children living with their mothers suggests that contact with nonresident parents exhibiting problematic behavior may not be in the childs best interest similar research is needed on the role of nonresident parents in the lives of children in grandfamilies particularly in light of the high level of disadvantage among nonresident parents that this study demonstrates our descriptive results suggest that children in grandfamilies have poorer outcomes than other children despite the fact that we have compared grandfamily children to other relatively economically disadvantaged children being raised by their mothers in particular we found that the incidence of addadhd was much higher among children in grandfamilies than those in other households and that this likely spills over into school interactions as teacherreported levels of cooperation were lower and oppositional behavior and inattention were higher among grandfamily children this suggests that children raised by grandparents have some unique needs particularly in the area of socioemotional development early trauma may explain some of these differences but because we also found high levels of contact with nonresident parents who had high rates of depression substance use and health problems research needs to consider how and whether this contact promotes or hinders childrens development and whether programs or interventions might be able to improve these interactions this study has several limitations first the sample is small including 84 grandfamilies and only 47 nonresident mothers and 34 nonresident fathers as noted previously our sample of fathers may be more advantaged and more involved than nonresident grandfamily fathers in general second this study has limited generalizability the ff study only sampled families in 20 large cities and the oversample of nonmarital births makes it more economically disadvantaged than the population at large however it is worth noting that the characteristics of the grandfamily grandparents in the ff sample are not that different from national samples in terms of age employment and education our findings suggest that although in some ways children in grandfamilies fare worse than other fragilefamily children their grandparent caregivers may serve as an important source of refuge most grandparents expect to raise their grandchildren for the long haul thus more research is needed to better understand their unique circumstances appendix a parenting in grandfamilies pilkauskas and dunifon page 16 grandfamilies m or not grandfamilies m or ttest school connectedness 012 000

using data from the year 9 fragile families and child wellbeing study n 3182 we investigated the characteristics grandfamilies grandparents raising their grandchildren with no parent present n 84 and compared them to other key groups including childrens nonresident parents and other economically disadvantaged families with children results show that grandparents raising their grandchildren were generally better off in terms of educational attainment marital status and economic wellbeing than the childs parents grandparents raising their grandchildren also had very similar characteristics to other disadvantaged mothers academic and socioemotional wellbeing was poorer among children in grandfamilies compared with those living with their mothers but parenting practices were very similar these findings suggest that although children in grandfamilies may be at a disadvantage academically and socioemotionally grandparent caregivers are in many ways similar to other fragilefamily mothers overall this study enhances our knowledge of an important yet understudied family type

introduction among the harmful traditional practices females genital mutilation was the focus of this study fgm is described as all procedures involving partial or total removal of external female genitalia or other injury to the female genital organs for cultural or nontherapeutic reasons this practice has longterm physiological sexual and psychological effects on women among which the immediate consequences are pains bleeding haemorrhage shock acute infection and transmission of hiv aids due to unclean conditions often associated with the procedure similarly the long term consequences include menstrual disorder painful sexual intercourse loss of sexual appetite fistula psychological consequences etc between 100 and 140 million girls and women in the world are estimated to be circumcised and 3 million girls are estimated to be at the risk of being circumcised every year this statement depicts that fgm still persists despite the fact that several measures have been taken by local communities governments and national as well as international organizations to eliminate it different justifications for the persistence of fgm are given in different societies in some of them girls pass through such procedure because it is accepted as an important part of their cultural identity while for others it is just for fear of stigmatization and rejection by their community there are also other justifications such as religion and girls marriageability these justifications indicate that fgm is a manifestation of gender inequality that is deeply entrenched in social economic and cultural structures fgm is most prevalent in northeastern africa countries where the prevalence varies from 97 in egypt to 80 in ethiopia several measures have been taken to bring about awareness on the harmful consequences of fgm over the past decade at international regional and national levels in spite of these efforts prevalence of fgm in many areas remains high and this makes the study relevant and timely that plays important role in identifying the main factors contributing to support for the continuation of fgm in ethiopia methods and materials this study was based on secondary data where the source of the data is the central statistical agency this data set was generated by the survey called ethiopian demographic and health survey carried out in 2005 the study covered the entire country in which both rural and urban areas are considered all the nine regions and two city administrations namely tigray afar amhara oromiya somali benshangul gumuz southern nations nationalities and peoples gambela harari addis ababa and dire dawa were included in the survey which was conducted from april 27 through august 30 2005 a twostage stratified clustered sampling design was used in edhs 2005 in the survey a representative sample of approximately 14500 households from 540 clusters was selected in the first stage 540 clusters were selected from the list of enumeration areas from the 1994 population and housing census sample frame as part of the second stage selection a complete household listing was carried out in each selected cluster the listing operation yields between 24 and 32 households from each cluster where the selection of these households was done systematically and made ready for the survey the 2005 edhs sample was designed to provide estimates for the health and demographic variables for the domains ethiopia as whole urban and rural areas of ethiopia and 11 geographic areas the survey employed three types of questionnaires namely household womens and males questionnaires the womens questionnaire which involves harmful traditional practices was the focus of this study information had been gathered from 14070 women of age 15 49 years using the structured womens questionnaire during the survey the actual data collection was conducted at the field level by 180 trained interviewers supervised by 30 field supervisors in which the entire field operation was coordinated by the csa the dependent variable was a request raised for all women who participated in the survey as to whether they support for the continuation of fgm practice expected binary responses was yes or no some of the corresponding independent variables included were educational status religion residence and region data were analyzed using spss for windows version 16 descriptive statistics was also used as the method of data analysis in addition to fitting the logistic regression model the data that corresponds to the variables considered by this study were extracted from the set of the dhs data particularly compiled from the womens questionnaire as the author was member of the csa during the study time permission to use the data was obtained from the deputy manager after explaining the purpose of the analyses results the support for the continuation of females genital mutilation decreased from 428 to 20 it was also observed that the support for the continuation of the practice ranged from 760 and 690 to 133 and 59 respectively the result for the other regions remained in between similarly the support for the continuation of fgm with respect to religion decreased from 458 among muslims to 201 among protestants all sociodemographic variables were associated with continuation of fgm the logistic regression analysis was consistent with the above finding according to the model output with respect to education status it was observed that those respondents whose education at primary level were 065 times less likely to support for the continuation of fgm compared to those with no education level or 065 95 ci similarly those with higher education level were 014 times less likely to support for the continuation of the practice than those with no education or 014 95 ci muslims were 134 times more likely to support for the continuation of the practice than orthodox or 134 95 ci furthermore the odds ratio for both catholic and protestants respectively were 052 and 071 times less likely to support for the continuation of the practice as compared to orthodox or 052 95 ci or 071 95 ci the result further showed that those who have knowledge of avoiding hivaids was 060 times less likely to support for the continuation of fgm compared to their counter parts or 060 95 ci it can be observed from the outputs that both results of the two analyses are consistent factors associated with perceived continuation……… zenebe fikrie discission this study showed that education modified the attitude towards the continuation of fgm both the descriptive and the logistic regression analyses of this study revealed that increase in education status results less support to the continuation of fgm that is the more people are educated the more they disregard the continuation of fgm making this result consistent with findings from other study women with higher education are expected to have more access and exposure to media and advocacy messages and possess greater awareness of the humane right implications it is also shown that the ratios of the proportions of women aged 15 49 who indicated that fgm should continue varies according to their level of education it is mentioned that in 10 of 15 african countries for which data are available support for the continuation of fgm is higher among women with no education compared to those with some education large proportion of women indicated that they believe religion requires fgm it was also mentioned that in 9 out of the 12 surveyed countries that collected information on religion greater proportion of muslim women supported the continuation of fgm differences in the levels of supporting for the continuation of fgm between muslim and christian women was particularly apparent in eritrea ethiopia and northern sudan similarly this study showed that muslim religion compared to orthodox religion was more likely to support for the continuation of fgm it was also more likely compared to catholic and protestant religions with respect to the support for the continuation of fgm it was also observed from the result of this study that somali and afar regions among other regions were more likely to support for the continuation of fgm in conclusion the study showed that women with low educational level from muslim religion from remote region and from rural residence had less awareness about harmfulness of fgm governmental or nongovernmental organizations should make intensive programs of informal education as well as awareness raising trainings through different social groups such as edir and holydays celebrations with emphasis to muslim dominant areas and rural residents

background females genital mutilation is one of the harmful traditional practices affecting the health of women and children it has a longterm physiological sexual and psychological effect on women females genital mutilation still remains to be a serious problem for large proportion of women in most subsaharan africa countries including ethiopia the objective of the study was to identify the main factors contributing to the support for the continuation of female genital mutilations in ethiopia methods this study was conducted based on secondary data obtained from the ethiopian demographic and health survey 2005 a twostage stratified cluster sampling design was applied for selecting the sampling units both descriptive and binary logistic regression analyses were used to analyse the data using spss for windows version 16regarding the fit of the model support for the continuation of fgm decreased with increase in education status furthermore muslim among other religions and somali and afar among other regions were more likely to support for the continuation of fgmthere was low awareness with less education status somali and afar regions rural residence and muslim religion were predictors of continuation of females genital mutilation

charter eviction litigating out of house and home margot young la décision tanudjaja c procureur général aborde de façon nouvelle et complexe la question des droits relatifs au logement en vertu de la charte canadienne des droits et libertés laction et linaction gouvernementale que lon caractérise de violations constitutionnelles et les vastes demandes de recours qui sy retrouvent reflètent laspect « pixellisé » des préoccupations actuelles relatives au logement un aspect essentiel à la compréhension de la crise de sécurité du logement au canada en rejetant la contestation à un stade préliminaire les cours supérieure et dappel de lontario risquent de rejeter la charte comme instrument pouvant jouer un rôle relativement aux préoccupations profondes de notre pays en matière de justice sociale plus particulièrement linvocation judiciaire sous forme de formule stricte de préoccupations relatives aux droits positifs et à la justiciabilité laisse les plus vulnérables dentre nous sans aucun recours constitutionnel et ce plus particulièrement lorsque des questions de justice complexes sont en jeu the case of tanudjaja v attorney general takes up the cause of housing rights under the canadian charter of rights and freedoms in a novel and complex way the government actions and inactions cited as constitutional breaches and the broad remedial requests reflect the pixelated picture of housing concerns necessary to understanding canadas housing security crisis in dismissing the challenge at a preliminary stage the ontario superior and appeal courts risk rendering the charter irrelevant to the deep social justice concerns that cross our country more specifically formulaic judicial invocation of concerns about positive rights and justiciability leave the most vulnerable among us constitutionally outside in the cold particularly when the issues of justice at stake are complex the recent struggle to access constitutional justice in the ontario case of tanudjaja v attorney general 1 marks well the current unsettled state of canadian constitutional protection for those without adequate housing the case along with its novel remedial request also illustrates the faceted character of housing as a social justice concern indeed the complex nature of housing rights underscores the importance of this case and the applicants specific and layered remedial request yet before any substantive consideration could be given to the issues raised the case has foundered the challenge vacated at the urging of the governments 2 by a trial court and an appeal court3 each overly bound to restrictive constitutional narratives while application for leave to appeal to the supreme court of canada pends the issues catalyzing the challenge thicken and worsen 4 the task this comment takes up is to critique the eviction to date of this case from the realm of justiciable constitutional claims it is my argument that unless socioeconomic rights cases are allowed to proceed on the bases on which this case rests we will largely confirm the irrelevance of constitutional protection for the most vulnerable in our society the challenges target of a wide range of government action and inaction and the call for a constitutionally imposed obligation to develop appropriately complex and nuanced ways to respond to the housing crisis may best lend effective and coherent force to the rights at issue the casting out of the tanudjaja challenge on preliminary grounds related to remedy and cause of action threatens to expand significantly the uselessness of the charter as a means of addressing some of the most pressing and pervasive social justice concerns of our time the evidence the applicants bring will be left unconsidered and the governments will face no constitutional pressure to respond to a human rights calamity thus my argument in this paper is specific to the kind of preliminary challenge tanudjaja faces without recognition of the legitimacy of challenges of this sort the key issues raised by housing rights will have no home within charter justice early criticisms of the charter as a document stuck in nineteenth century liberalism blind to material inequality and thus with no promise of meaningful rights for the economically marginalized will be confirmed5 i housing in canada to state the obvious t he provision of affordable housing is a basic pillar of a civilized society 6 among basic needs housing is clearly front and centre the case for housing as a key determinant of health life chances social inclusion and wellbeing has been fully and convincingly made 7 from the south african postapartheid context judge albie sachs when on that countys constitutional court wrote that those without minimally adequate housing live lives spent in systematized insecurity on the fringes of organized society 8 the indian supreme court links access to housing with full human personhood 9 and in canada too it is acknowledged that it is difficult to do well on any measure of human flourishing without access to housing the british columbia court of appeal in victoria v adams referred to the need for shelter for the homeless as involving the needs of some of the most vulnerable members of our society for one of the most basic of human needs shelter 10 a fixed address is a practical necessity for the realization of citizenship rights 11 the persistence of housing insecurity in the face of such indisputable argument is shameful distinctions between shelter and a home are also important pieces of the conversation about housing provision and inadequacy there is considerable literature on this too 12 such an observation signals why adequate housing matters so much and why mere shelter provision is not enough as fox omahony states it is the relationship between the person and her or his home that marks home out as different from other types of property 13 the social psychological and cultural factors which a physical structure acquires through use as a home stand out 14 adequate policy discussion of this issue will note the intangible and uncommodifiable aspects of housing most importantly the concept of home 15 housing policy that meets our human rights commitments must take this into account ii the right to housing international human rights treaties recognize access to adequate housing as a fundamental human right prioritizing recognition of housing as a basic requirement of personhood thus the universal declaration of human rights lists housing as a feature of the entitlement to a standard of living adequate for health and wellbeing 16 13 fox omahony supra note 7 at 157 14 fox supra note 12 at 590 15 hohmann supra note 8 at 169 16 this idea has been under development since the latter part of the twentieth century following the world habitat conferences in vancouver and istanbul these two international gatherings demonstrated international political recognition that housing is a human right the full text of this section of the universal declaration reads everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family including food clothing housing and medical care and necessary social services and international covenant on economic social and cultural rights is understood to guarantee adequate housing 17 womens equal right to housing is also protected in article 14 of the convention on the elimination of all forms of discrimination against women 18 considerable guidance is available from international and national commentary on what adequate housing entails general comment no 4 from the committee on economic social and cultural rights develops what is meant by adequate housing in particular seven features fill out the concept of adequacy security of tenure for all forms of housing occupation provision of basic services materials and infrastructure affordability as reflected in percentage of average income level habitability such that housing provides protection and enough space accessibility for those with barriers to access location that is safe and proximate and cultural adequacy reflecting cultural identities 19 this list is useful to thinking about the requirements of adequacy indeed it is necessary to taking seriously the subtleties of the shelterhome connection but the united nations catalogue is a starting place only as westendorp points out these criteria are phrased in a genderneutral manner each she argues needs to be more nuanced to take account of the situations women face in procuring adequate housing for example westendorp would expand the list adding to it the aspects of safety and dignity at home reflecting concerns about the widespread domestic abuse experienced by women 20 the current housing situation in canada is information that is neither new nor generally unknown the argument that there is a madeincanada housing emergency has been repeatedly articulated by both domestic and international actors report after report documents from a domestic canadian perspective the range and degree of housing inadequacy that faces too large a number of those resident in canada 21 for example a 2010 report from the wellesley institute states that deep and persistent housing insecurity and homelessness are truly nationwide the right to security in the event of unemployment sickness disability widowhood old age or other lack of livelihood in circumstances beyond his control universal declaration of human rights ga res 217 un gaor 3d sess supp no 13 un doc a810 71 at article 25 17 article 11 states the states parties to the present covenant recognize the right of everyone to an adequate standard of living for himself and his family including adequate food clothing and housing and to the continuous improvement of living conditions the states parties will take appropriate steps to ensure the realization of this right recognizing to this effect the essential importance of international cooperation based on free consent issuesfrom iqaluit in the north to st johns in the east to victoria in the west 22 at the international level experts have weighed in the recent report by the then united nations special rapporteur for adequate housing referred to a crisis of homelessness and inadequate housing in canada 23 in a country as wealthy and with such a high general standard of living as canada one is rightly appalled that our governments allow this degree of homelessness and housing insecurity to continue we should feel a principled impatience for change canada has no national fixed definition of homelessness the canadian mortgage and housing corporation canadas national housing agency defines housing affordability as spending less than 30 percent of beforetax household income on housing costs 24 this definition thus identifies households in core housing need as households where more than 30 per cent of pretax income is spent on shelter costs 25 in 2010 the incidence of core housing need was 132 per cent for urban households up from 123 per cent in 2007 26 over the six year period from 2005 2010 175 per cent of urban individuals spent at least one year in core housing need 27 loneparent households and oneperson senior female households are the household types with the highest core housing need for these and other low income households the private rental housing market typically requires considerably more than 30 per cent of income there are too few private and public rental units that are affordable and adequate the dominos fall such that those with the fewest resources scramble for a shrinking supply of affordable cheap housing 28 individuals respond to housing insecurity in a range of ways many households react to the high and unreachable cost of housing by consuming bad housing 29 women in particular may be unable to leave abusive domestic situations 30 younger women will trade sex for shelter 31 families live in spaces that are too small with mould or infestations households in core housing need are likely to compromise full and dignified involvement in canadian society in exchange for maintaining some form of housing and some simply go homeless vancouver serves as a good example of the range of canadian urban housing circumstances at its most extreme clearly vancouver has a homelessness problem this is often discussed in many neighbourhoods of vancouver it is hard to miss the latest homelessness count took place in the spring of 2014 and showed that vancouver currently has the highest homeless population since records have been kept a total of 1803 people identified as homeless with 536 living on the street and 1267 in shelters 32 more generally in vancouver the incidence of core housing need is 201 per cent the highest in urban canada 33 accompanying this situation as it plays out across canada is a general absence of effective governmental strategy to reduce homelessness and housing insecurity at the federal and provincial levels 34 in 2004 two canadian housing scholars wrote that canadas housing system is now the most privatesector marketbased of any western nation including the united states 35 the canadian policy profile that shapes this picture from a decade ago certainly has not changed indeed the path forward has been even more so one of sustained federal government withdrawal from the business of housing provision 36 in 2006 international human rights expert members of the united nations committee on economic social and cultural rights called for canada to implement a national strategy for reduction of homelessness that includes measurable goals and timetables consultation and collaboration with affected communities complaints procedures and transparent accountability mechanisms in keeping with icescr standards 37 efforts have been made to advance such a national strategy in parliament one that reflects the human rights focus of the committees recommendation twice a private members bill has been introduced into the house of commons that would obligate the government to develop a national strategy and twice the private member bill in question has been effectively vanquished 38 in the current conservative party majority controlled parliament a third attempt would be equally futile the political willingness and boldness at all levels of government to implement a fix to the failed system are nowhere in evidence 39 32 greater vancouver regional committee on homelessness results of the 2014 homeless count in the metro vancouver region online 33 toronto is 179 per cent and halifax is 147 per cent see canadian housing observer 2013 supra note 26 34 one province alberta has implemented a strategic plan called a plan for alberta ending homelessness in 10 years online for an overview of government action and inaction see the affidavit of michael shapcott director wellesley institute online 35 david hulchanski michael shapcott finding room options for a canadian rental housing strategy at 6 36 gaetz et al homelessness supra note 7 37 cescr concluding observations 22 may 2006 ec12canco4 ec12canco5 at para 62 38 the first attempt died on the order paper when a general election was called the second attempt was defeated at second reading by the coordinated governmental member vote against it 39 strange supra note 6 at 1 government default cannot be justified by reference to the difficulty of the issue certainly the affordability gap so many groups encounter does not permit easy resolution is housing too expensive or is income too low 40 solutions will not be cheap and simple but options abound as to policy choices that could address the housing crisis for example changes to either housing costs or to individual income and purchasing power generate two sets of different policies each from different ends of the supplydemand model aiming at the same outcome increased housing affordability some argue for supplybased approaches of construction subsidies and social housing others for more demandbased policies such as shelter subsidies and income transfer programmes 41 a wide range of potential policy solutions beckons and while what is best and at what level of governmentfederal provincial or municipal or some combination of all threeit should be implemented are complex and open questions 42 none of this difficulty justifies government inaction or neglect this observation about multiple policy options foreshadows my next point desired housing outcomes must be appropriately and variously nuanced to the populations most vulnerable to housing insecurity the groups experiencing housing inadequacy in canada are diverse housing insecurity and the forms it takes vary while street homelessness is a visible and stark reminder of this injustice other experiences of housing insecuritycrowded shelter insecurity of tenure unhealthy housing couchsurfingare also concerning deserving significant policy attention thus homelessness counts give a picture of part of the problem they not only undercount the sheltered and unsheltered homeless but by definition ignore a fuller range of housing insecurity and variety is also reflected by the diversity of groups in canadian society that disproportionally face housing and shelter crises housing insecurity as indigenous peoples experience it on reserve needs specific analysis persons with disabilities similarly have particular unique concerns youth new immigrants families loneparent families add to this list of socioeconomically configured interface with canadas housing market and supply it is clear that a minimum number of considerations may pertain to what constitutes adequate housing but these features will be achieved in different ways for different groups of individuals indeed the list generated by cescr as already mentioned may need expansion in reference to many groups specific socioeconomic features ensuring effective and adequate housing provision requires a prismatic approach the general picture must be fractured into distinct images of housing as the various marginalized and disadvantaged groups in canada experience it 43 the multiplicity of housing needs and of responses to housing insecurity requires a full creative and coordinated range of policy responses capturing exactly how canadas housing crisis is compounded by the diversity of canadian society goes beyond the scope of this paper but because this observation is critical to the argument of this paper i do want to provide one example of how housing policy must be responsive to particular groups needs experiences and situations the illustration i use looks to gender and how this identity feature configures housing analysis 40 see the discussion in strange supra note 6 at 4 41 strange supra note 6 at 4 42 strange supra note 6 at 7 43 gurstein young supra note 28 at 8 without doubt the disadvantages and harms of inadequate housing are like much else in society gendered 44 how women are affected and how they cope with inadequate housing reflect the options limitations and structures that inflect patriarchy in 21 st century canada two scholars recently wrote h ousing systems and opportunities are embedded within structured and institutionalised relations of power which are gendered 45 these gendered relations of power shape policy standardize institutions and configure social programmes thus in 2009 the united nations special rapporteur on adequate housing heard evidence from canadian groups that the lack of adequate and secure housing particularly impacts women who are disproportionally affected by poverty homelessness housing affordability problems violence and discrimination in the private rental market 46 more generally feminist scholars detail concerns about womens place in the contemporary postindustrial city 47 the gendered social geographies 48 that shape and are shaped by housing options are critically essential to the effective setting and assessment of housing policy statistics tell this gendered tale about housing some examples follow sexual abuse and domestic violence are major causes and consequences of homelessness among women 49 one study found that one in five homeless women interviewed reported having been sexually assaulted while on the streets or homeless 50 a recent toronto study found that 37 per cent of the homeless women interviewed had been physically assaulted in the prior year and 21 per cent had been sexually assaulted or raped one or more times in the same time period homeless women were ten times more likely to be sexually assaulted than homeless men more likely to have serious physical health problems and twice as likely to have received a mental health diagnosis 51 similarly in her study of homeless women in ottawa halifax and vancouver neal found that a significant number had experienced violence while living on the street they have been clubbed raped molested and taken advantage of while seeking protection from harm 52 women disproportionately experience discrimination in the rental market discrimination based on poverty receipt of social assistance race marital status and intimate violence the affordability gap is a huge motor for housing insecurity here again gender tells men earn more than women women are disproportionately among the poorest of the poor while womens involvement in the paid labour force steadily rises making a significant contribution to canadas economic growth this involvement nonetheless is at lower wages than those paid men women are as a recent study looking at employment in canadian cities notes three times as likely to work in parttime jobs and nearly twice as likely to work for minimum wages compared to men 53 sole female parents and elderly women register in higher numbers in this group 54 not surprisingly then these groups also rank as already noted as in high core housing need 55 other scholars more conceptually point to how womens gendered position in society has also meant that women as disproportionately the keepers of the hearth have long understood the meaning of housing beyond provision of shelterthat housing has unique economic psychological and symbolic significance with profound impacts on a familys wellbeing and quality of life 56 and because of womens social location the concrete issues of safety adequacy proximity to workchild care transportation affordability all reflect social orders structured by gender and by womens unique placement ideologically in public and private orderings of space kamwah chan and patricia kennett the two scholars referred to above identify three dominant discourses about gender and housing each discourse captures an important element of the import of gender in this area and consequently each deserves a quick review the first discourse comes out of the urban planning tradition where feminist planners concerned how housing design and the lived environment impact women have argued since the nineteenth century that improved housing and urban design could free women from many aspects of their daily subordination 57 today this perspective has matured and now looks more complexly at the relationships between gender space and housing in important ways susan fainstein and lisa servon theorists cited by chan and kennett look to social transformation in power relations from within a planningsocial policy context to lay the groundwork for the creation of nonsexist cities 58 the housing welfare discourse a second approach is located by chan and kennett as an offshoot of the welfare feminism of the 1970s and the 1980s with its focus on social welfare as the mechanism to achieve gender equality 59 availability of womenspecific housing resources and increasing housingrelated services for women are policy objectives of this strand the literature from this perspective thus identifies a number of special housing needs for women representative proponent roberta woods argued in 1994 about the need for research about 53 kate mcinturff the best and worst place to be a woman in canada an index of gender equality in canadas twenty largest metropolitan areas at 78 online canadian centre for policy alternatives 54 vancouver in many ways represents a useful snapshot of womens equality issues in a large canadian city roughly equivalent to the national average vancouvers employment rates show 66 percent of men and 58 percent of women employed around 42 percent of working women hold fulltime jobs the wage gap between women and men however is among the biggest in canadas urban centres women earn 30 percent less than their male peers data taken from mcinturff supra note 53 at 43 55 see note 25 56 elizabeth a mulroy women and housing affordability in the united states in chan kennett supra note 20 at 52 57 chan kennett introduction supra note 45 at 2 chan kennett tell of melusina peirce who in 1870 proposed neighbourhood kitchens surrounded by kitchenless housing to facilitate housework cooperatives with the goal of reducing womens household burdens and confinement in the home 58 susan s fainstein lisa j servon introduction in susan s fainstein lisa j servon eds gender and planning a reader at 7 59 chan kennett introduction supra note 45 at 3 women in relation to the delivery and management of housing services ensuring a gender specific perspective on housing provision production and management 60 the last approach is the one favoured by chan and kennett the social constructionist discourse an offspring of neomarxism critical theory and postmodernism this approach looks at how gender inequality is constructed in the housing system 61 critique focuses on genderblind assumptions central to housing policies making the basic theoretical observation that housing is never merely bricks and mortar 62 homeless women or lone parent women for example are disadvantaged by and unreflected in policy as dominant conceptions of the problem remain gender blind at the centre marginal tinkering to add on to mainstream policy or projects some accommodation 63 for womens special needs fails to undo the central gender hegemony of the housing system 64 for an illustrative argument leslie kern writes that w omens housing needs whether as heads of households or members of a twoadult household have been subsumed into what is largely a heteronormative family policy wherein womens housing needs were considered merely a corollary of the male breadwinners needs womens concentration in lowend rental and other types of alternative tenure was viewed as a transitional phase in womens housing careers rather than a genuine social and economic pattern that deserved policy consideration 65 more generally and not with gender specificity housing scholar jessie hohmann writes that …the way identity is recognised socially and legally is often mediated through relationships with the house and home both as a physical material thing and as an ideological construct 66 hohmann reinforces this contention at another point of her argument when she argues that housing policies can be tools of social reorganization even social engineering 67 hohmanns book the right to housing law concepts possibilities has been a useful reference the book contains an interesting discussion highlighting how adequate housing provision for women is complicated by the specific ideological framing of women as homemakers she notes that even when housed women can be practically homeless the households association with the nuclear family and womens role in that family form accord women a version of privacy…more akin to privation than refuge 68 linked then to this observation are the reams of feminist research showing how our legal and social systems traditional understandings of the home as sanctuary definitionally shielded from public scrutiny have contributed to significant violence and deprivation for women within the home hohmanns discussion thus illustrates just how complexly and profoundly gendered are our dominant notions 60 roberta woods introduction in rose gilroy roberta woods eds housing women at 7 61 chan kennett introduction supra note 45 at 3 62 ibid 63 pun intended 64 chan kennett introduction supra note 45 at 4 65 kern supra note 47 at 66 66 hohmann supra note 8 at 167 67 ibid at 183 68 ibid at 185 of housing arrangements this type of social constructionist argument casts critical light on traditional notions of adequacy it also hohmann would argue makes the case for framing womens housing issues in terms of a right to adequate housing the individualistic frame of that entitlement claim pulls womens needs out from within the private reaches of the family thus she argues challenging the traditional and cellular form of society 69 we can through such a political claim interrogate the linkage of woman and home and thus radically recast womens housing concerns from private demands to public obligations 70 this is she argues part of a strategy for equal social citizenship for women interestingly this conversation has elements consonant with the notion of substantive equality as that notion has been developed by feminist legal scholars in canada 71 the housing analysis advocated here is sensitive to how difference and diversity are manifested and how each are or are not reflected and engrained in social policy and law this conceptualization allows for greater diversity than gender alone can signify recognizing that women are also identified by race ability culture and class for example chan and kennett thus argue that the social constructionist approach can be sensitive not merely to cultural meaning but also to material deprivation and outcome housing design access to housing resources and housing ideology are all part and parcel of the social construction process 72 urban theorist leslie kern in a marvelous book on marketing condominiums to women writes in a similar vein about neoliberal urbanisms reinscription through a citys built spaces of particular identities and subject positions 73 like hohmann kern sees the ways in which housing provision and the ideological assumptions underlying it shape in particular ways womens opportunities for equal inclusion or gendered exclusion in the city the discussion about gender and how it matters in relation to housing provision and policy shows us that housing provision necessarily engages rights of gender equality as captured by both section 7 and section 15 of the charter one author to this end writes that two decades of quantitative and qualitative research into womens position in the housing market have produced a picture of entrenched systemic disadvantage 74 and we know that the specific vulnerabilities attached to being female in our society are amplified exacerbated and made more intransigent by the lack of adequate housing documented across the country it also means that any remedial response to this problem must be sensitively and variously configured to take into account such evidence of intersectionality and diversity in vulnerability and need any plan or solution to womens housing insecurity must take into account the particularities of womens experiences across a wide range of diverse circumstances the simple conclusion for wider policy housing insecurity at largeits causes manifestations and potential solutionsis a necessarily pixelated picture a general concern about and broad characterization of the housing issue are possible but these must rest on and devolve actively into recognition of complexity and diversity no simple single policy solution is desirable or possible housing provision has long been cited as a wicked problem 75 solutions to the problem at large are necessarily multifaceted and require nuanced calibration across a number of economic social and cultural fronts addressing housing concerns for one demographic may ignore complicate even frustrate solutions required for other groups and judicial orders unless nuanced to this reality and reflective of a moving shifting picture rather than simple snapshots will not fix the problems absent this sort of fractured multiple and inclusive lens one risks the decontextualized and abstract interpretations of the right to housing that currently exist in the majority of legal interpretations of the right 76 or as hohmann puts it housing provision too simply understood might provide a floor…but also a ceiling to equality and inclusive social citizenship 77 this conclusion to the first half of the paper takes us nicely to consideration of the tanudjaja case iii tanudjaja v attorney general the first parts of this paper have touched on key points of the context out of which the constitutional challenge of the tanudjaja case arose more specifically the argument has been made that housing policy that effectively addresses canadas housing crisis will necessarily be complex and complicated orchestrated with different groups in mind and involving a range of programmes fiscal measures and levels of governments with this initial discussion in mind i move now to discuss briefly the challenge the tanudjaja applicants brought and the bases on which the preliminary motions to dismiss the challenge were successful at the ontario superior court of justice and subsequently at the ontario court of appeal this conversation sets up my final contention that the trial judgement if left standing leaves very little space for our most serious and thus large and complex social justice failures to have adequate constitutional register my goal is not to canvas and critique fully the trial court judgment rather the slice offered is one that focuses on the key dangers of the trial judgment and the court of appeals support of that judgments conclusion on justiciability to progressive charter development in the area of social justice and rights the tanudjaja case was brought by four individual applicants all of whom are in circumstances of significant housing insecurity their experiences reflect the range of groups most vulnerable to housing inadequacy sole female parents the disabled lowincome families and the very poor 78 these individuals were joined in the application by an ontario based non 75 gurstein young supra note 28 at 6 76 hohmann supra note 8 at 197 on the complexity of capturing fairness concerns in social justice resolution see natasha affolder transnational conservation contracts 25 leiden j of international l 443 at 455 77 ibid at 217 78 interestingly justice lederer felt compelled to comment that not all of the applicants were homeless implying one worries that this fact somehow reduced the urgency or credence of their claims it is an odd and uncomfortable start to the judgment tanudjaja supra note 1 at para 13 profit housing advocacy organization the centre for equality rights in accommodation 79 several groups successfully sought intervener status for the hearing of the preliminary motion 80 all argued in favour of the case proceeding and such extensive intervener activity at this preliminary stage signals the importance social justice rights groups across canada have assigned the challenge the initiating application was issued 26 may 2010 the claim can be simply summarized the canadian charter of rights and freedoms 81 must be read to impose an obligation on the governments of canada and ontario each to have in place policies and strategies ensuring affordable adequate and accessible housing for all 82 yet the applicants stated the governments have created and sustained conditions that lead to support and sustain homelessness and inadequate housing as such these governments are in breach of section 7 and section 15 of the charter three important and interconnected components make up the rights claims first the applicants argue that the governments have instituted changes to existing legislation policies programs and services that have resulted in homelessness and inadequate housing second it is claimed that new policies were implemented without adequate and constitutionally required efforts to address impacts on housing access and on vulnerable groups access in particular to adequate housing consequent negative effects on homelessness and housing insecurity have gone unaddressed or unameliorated third and finally the argument maintains that neither government has undertaken appropriate strategic coordination to ensure that government programmes protect the homeless or those most at risk of homelessness 83 this mix of action and inaction imperils life liberty and security of the person for those without adequate housing in a fundamentally unjust manner and as well infringes the right to substantive equality for these same individuals the individual applicants various circumstance and histories illustrate these negative rightsinfringing outcomes the remedial order requested reflects the tripartite nature of the constitutional wrongs claimed and itself has three distinct elements first and most direct was the request that the court issue a series of declarations detailing how the governments are in breach of their constitutional obligations under sections 7 and 15 including by creating conditions of housing insecurity and failing to implement effective strategies aimed at reducing and eliminating housing insecurity second the applicants sought judicial orders that housing strategies be developed and implemented according to a range of conditions and policy parameters these considerations involve such things as consultation with affected groups and various accountability measures 84 key to effective rights implementation third the applicants asked 79 the centre for equality rights in accommodation is a nonprofit agency that advocates for housing rights and that provides services for lowincome tenants and the homeless for more information about this organization see online 80 these groups were amnesty canada escrnet coalition david asper centre for constitutional rights charter committee on poverty issues pivot legal society income security advocacy centre and justice for girls 81 canadian charter of rights and freedoms part i of the constitution act 1982 being schedule b to the canada act 1982 1982 c 11 82 this was also the opinion of international human rights experts with respect to canadas international human rights commitments ibid text at xx 83 tanudjaja supra note 1 at para 16 applicants amended application 84 timetable reporting and monitoring regimes outcome measurements and complaints mechanisms that the court retain supervisory jurisdiction that is the court administer the judicial orders and oversee government compliance in light of declared constitutional obligations 85 the response of the attorneys general of canada and ontario was to bring motions to dismiss the application both governments argued that among other things it was plain and obvious that no reasonable cause of action was disclosed and the issues raised were not justiciable on the basis of the motions the court dismissed the application 86 justice lederer wrote the decision on the preliminary motions employing a number of recurring themes determinative of the dismissal breadth of considerations relevant to the policies and strategies challenged by the applicants no precedent for rights to housing radical change requested in charter law imposition on the public purse and institutional boundaries two themes stand out no protection for positive rights and the nonjusticiability of the challenge the motion judges handling of each shows a failure to appreciate the nature of rightsconceptually and jurisprudentially 87 the judgment also ignores the wise caution that the approach to charter rights must be a large and liberal one it is presumptively problematic to foreclose discussion at a preliminary stage 88 there is by the way some irony to this judgment dismissal requires that it is plain and obvious that there is no cause of action the judgment is 56 pages long a lengthy argument on the merits to show there is no argument on the merits iv negative and positive rights lederer js judgment engages considerably with case law in reference to both section 7 and section 15 but common across these two discussions is the insistence that under neither right are positive government obligations located no positive obligation has in general been recognized as having been imposed by the charter requiring the state to act to protect the rights it provides for 89 that is to paraphrase the judge to the extent that the applicants are citing government failure to act as a charter infringement their arguments must be unsuccessful the distinction between positive and negative rights has been written about extensively and is a common referent in canadian and american case law academic commentary notes that the distinction captures no clear division with respect to rights characterization 90 most rights 85 applicants amended application supra note 82 at 34 86 for the full text of each motion and other relevant documentation in the litigation see online 87 this point is explored in more detail in the text that follows 88 also imperilled as the appeal factum for the womens legal education and action funds intervention at the court of appeal level states is the principle of constitutionalism as articulated by the supreme court in the secession reference every state action must accord with the constitution and there must be reasonable opportunity for full assessment through judicial review as cromwell j wrote in canada v downtown eastside sex workers united against violence society 2012 scc 45 2012 2 scr 524 at para 31 on public interest standing state action should conform to the constitution and statutory authority and that there must be practical and effective ways to challenge the legality of state action this principle was central to the development of public interest standing in canada 89 tanudjaja supra note 1 at para 103 90 stephen holmes cass b sunstein the cost of rights why liberty depends on taxes martha jackman charter remedies for socioeconomic rights violations sleeping under a box in justice robert j sharpe kent roach ed taking remedies seriously vienna declaration and programme of action un doc aconf 15723 montreal even some of the most classical civil and political rights long enforced by our courts require a mix of government forbearance and government action the right to vote say requires not merely the absence of barriers to voting but proactive establishment of electoral infrastructuresetting up electoral commissions polling stations hiring electoral officials and so on all of these have considerable impact on government resources involving complex government programmes and legislation so while some analytical usefulness attaches to thinking about what type of government responses a particular right requires it is a mistake to fail to acknowledge that most rights require a bundle of both government withdrawal and government provision thus louis arbour when united nations high commissioner of human rights urged moving away from such simplistic or categorical distinctions 91 too many canadian judges miss this point those who give too much credence to the distinction using it to provide a rigid typology of rights that can or cannot be subject to judicial enforcement miss important insights about rights protections they short sheet charter claimants without any sound analytic basis this is because they fail to realize that so many rights that are standard fare for judicial enforcement are no less political or positive than those socioeconomic rights currently under dispute the older more classic rights have simply through the accretion of tradition been lifted above the fray of contestation 93 most critically for the applicants case and for this comment lederer js use of the distinction between positive and negative rights sets up an understanding of charter rights protection that ensures little constitutional space for social justice struggles policy solutions for resolution of canadas housing emergency widely require government programmes and spending no housing advocates call for more government pullout in the area of housing provision absent judicial willingness to recognize positive charter obligations our charter will be mostly mute on the injustices of widespread homelessness and inadequate housing v justiciability justiciability issues focus on the institutional appropriateness of a claim for judicial review with the advent of the charter and its increasing invocation by social activists frustrated by political blind alleys the issue of justiciability has also been the focus of much judicial and academic commentary 94 lederer j raises his concerns about this issue in relation both to the substantive principles on womens economic social and cultural rights online international federation for human rights 91 louise arbour freedom from want from charity to entitlement online un office of the high commissioner for human rights 92 see for example the following passage from the dissent of justice bastarache in gosselin v quebec 2002 scc 84 2002 4 scr 429 at para 218 the appellant and several of the interveners made forceful arguments regarding the distinction that is sometimes drawn between negative and positive rights as well as that which is made between economic and civil rights arguing that security of the person often requires the positive involvement of government in order for it to be realized this is true the right to be tried within a reasonable time for instance may require governments to spend more money in order to establish efficient judicial institutions 93 hohmann supra note 8 at 237 94 see eg paul oconnell vindicating socioeconomic rights international standards and comparative experiences david wiseman taking competence seriously in margot young et al rights claims about section 7 and section 15 and to the character of remedy requested his conclusion in both regards is that … the application is misconceived there is an inherent tension between sic the institutional boundaries that on one hand define the authority of the legislature and on the other hand determine the responsibility of the courts to protect the substantive entitlements the charter provides… 95 the argument appears to have two components first lederer j states that the charter does not empower courts to decide upon the appropriateness of policies underlying legislative enactments 96 what he means exactly by this is not clear but lederer j would have done well to attend to what the supreme court wrote in canada v phs community services society finally the issue of illegal drug use and addiction is a complex one which attracts a variety of social political scientific and moral reactions while it is for the relevant governments to make criminal and health policy when a policy is translated into law or state action those laws and actions are subject to scrutiny under the charter the issue is not whether harm reduction or abstinencebased programmes are the best approach to resolving illegal drug use but whether canada has limited the rights of the claimants in a manner that does not comply with the charter 97 policy decisions are not immune from charter review true phs had concrete state action at issuethe statute and the ministers refusal of exemptionbut as the court said in that case the question is the impact on claimant rights by the government the concern in either case is not about challenging policy per se in the abstract the second element of lederer js argument is about the breadth and number of policies at issue under section 7 and section 15 and over which remedial supervision is requested lederer j seems confounded by the fact that no single government programme or law fronts the challenge he concludes that the challenge points to so many programmes that what the applicants require is baldly consideration of how our society distributes and redistributes wealth 98 this is he continues an important set of questions but the courtroom is not the place for their review 99 one might think that concerns about judicial activism and inappropriate judicial meddling with legislative prerogatives would be assuaged somewhat by the open ended and indeterminate nature of the order requested no specific concrete measures are requested simply that the two governments put their institutional minds to the development and adoption of some strategy to reduce and eliminate housing insecurity in a framework that prioritizes the needs of vulnerable groups but the motions judge rejects an understanding of the remedial request as retaining significant government discretion instead the remedial request is castigated as the offering up of a trojan horse 100 lederer j is correct in the first assertionrights are ultimately about wealth distribution rights are costly and require tradeoffs 101 but the decision to incur such costs was made with the charters enactment and the task of ensuring that these costs are engaged assigned to the judiciary two american academics make this point in practice judges defer much less in fiscal matters than they appear to simply because the rights that judges help protect have costs 102 moreover complexity and gravity cannot be reasons for charter immunity challenges that like the trojan horse are packed reflect the unavoidable complexity of the modern state breadth of problem here signifies depth of problem and problems that significantly engage serious and numerous aspects of governance should not thereby be presumptively free of charter oversight that would be perverse lederer j is perceptive about the importance of housing rights and the scope of government action neededhe simply runs in the wrong direction with these observations these points ought to make charter applicability all the more compelling not frightening general concerns about justiciability continue to stalk charter litigation 103 other jurisdictions too grapple with the question 104 the british scholar hohmann notes courts have made determination on the right to housing without bringing the economics of states to their knees or marginalising the elected branch of government to the point of pointlessness … practical concerns can be overcome 105 hohmann also notes quite rightly that the two argumentsnegative versus positive rights and justiciabilityare importantly connected recognition of the inevitable costs of even negative rights takes that sting away from socalled positive rights and from much of the justiciability concern the suggestion that the right to housing is uniquely problematic fades away two other jurisdictions have enshrined high profile 106 rights to housing albeit through somewhat different pathways in their respective constitutional law this paper does not allow the opportunity to explore this in detail but it bears noting that both south africa and india have seen considerable political struggle around adequate housing provision leveraged through constitutional litigation while neither provides a resounding triumph for housing claims both examples show that there is space in constitutionalism for a rights based argument about housing insecurity this brief mention is included to point out more substantively that denial of constitutional recognition of a right to housing ought not to be the foregone conclusion the 100 ibidat para 65 101 holmes sunstein supra note 90 at 5152 102 ibid at 29 103 see malcolm langford the justiciability of social rights from practice to theory in malcom langford social rights jurisprudence emerging trends in international and comparative law 104 see for example the discussions that follow on south african and indian case law for more elaboration generally see hohmann supra note 8 105 hohmann supra note 8 at 234 106 ibid at 94 motions judge appeared to assume at least that ought not to be a conclusion reached at this stage of canadian jurisprudence in a preliminary motion to dismiss nonetheless the motion judges arguments withstood review at the court of appeal two of the three justices hearing the appeal pardu and strathy jja upheld the decision of the motions judge to dismiss the action the third justice feldman ja would have allowed the appeal returning the application to the lower court for adjudication on the merits the reasons for the majority dismissal of the appeal focus on the question of justiciability pardu ja is author of these reasons and summarized this concern as involving a normative inquiry into the appropriateness as a matter of constitutional judicial policy of the courts deciding a given issue or instead deferring to other decision making institutions of the polity 107 that is more simply put the concern circles on whether or not this is a question purely of the political realm or one with sufficient legal aspect to engage judicial contemplation thus at stake for these justices is the distinction between legal and political questions and the relevance of that distinction to determination of judicial institutional capacity 108 sufficient legal content is required for adequate judicial competency over the question 109 the majoritys conclusion is that there is insufficient legal content to this claim to engage a courts decision making capacity the majority reaches this outcome by reframing the application as in essence the assertion that canada and ontario have given insufficient priority to issues of homelessness and inadequate housing 110 this reduces the claim to a more simple and purely policy challenge one that to paraphrase the supreme court of canada in canada v phs community services society focuses on government policy that has not been translated into law or state action 111 so understood the challenge appears to ask the court to engage in the kind of policy assessment and divination best left to the legislative branch the sticking point for the majority at the court of appeal is that no specific law or government action is singled out by the challenge a specific focus on one law is the majority argues an archetypal feature of charter challenges under section 7 and section 15 112 here there is no such focus and the claim is dismissible it is thus argued on the grounds of nonjusticiability 113 two aspects of the majority argument bear critical examination first the recasting of the challenge as simply to policy alone is incorrect the challenge is not to policy hovering in some realm separate from government action and from practical effect the pleadings establish that the applicants claim is much more complex and faceted targeted as already noted is a broad range of government actions and inactionsall of which the applicants claim have significant rightsdestructive effects in canadian society second justiciability as the majority understands and deploys the notion connects to two issues the majority 107 tanudjaja onca supra note 3 at para 19 quoting from canada v canada 1989 2 scr 49 61 dlr 604 at paras 9091 108 tanudjaja onca supra note 3 at para 21 109 ibid at para 35 110 ibid at para 19 111 phs supra note 97 at para 105 112 tanudjaja onca supra note 3 at at para 22 113 this is also the avenue by which the ontario court of appeal majority distinguished this case from the supreme court of canada decisions in phs supra note 110 and in chaoulli v quebec 2005 scc 85 2005 1 scr 791 the majority attempted to keep alive the possibility of charter scrutiny of a network of government programmes but only where it appears there is more certainty of a specific rights infringement states it is leaving alone the issues of positive versus negative obligations and of novel claim making under the constitution it is from the perspectives of these two issues that the dissenting judgment sets up its opposition to the majority opinion to repeat the first issue connected to the finding of nonjusticiability the key concern of the majority is really the question of whether both state action and inaction are subject to charter scrutiny the argument that policy absent translation into government action is immune from charter standards relies upon the idea that unless the government positively acts a policy decision to not act is untouchable a claim asserting a general right to housing under section 7 is thus the majority asserts a doubtful proposition 114 yet this contention about what is or isnt protected under the charter is not certain law as the majority choice of language itself indicates at the stage of preliminary review on a motion to dismiss best guesses as to legal outcomes as yet undecided are unsound reasons for dismissal such a question of constitutional rights interpretation given that it is an open question to date must be allowed to go to argument on the merits to collapse it into a finding of nonjusticiability is faulty elision of issues 115 the majority compounds this error in its additional reasoning about section 1 and remedial possibilities there must also be the court asserts an impugned law whose objective can be evaluated under the oakes test of section 1 application 116 such an opinion would condemn any and all sections of the charter to assertion of negative obligations only the argument is based on too literal a reading of the oakes test 117 the requirement that the features of a law be assessed finally the majority takes issue with the character of the remedial request arguing that there is no judicially discoverable and manageable standard for assessment of the adequacy of any resulting housing strategy in relation to the conditions the remedial request seeks to impose 118 but remedial selection can be varied and crafted to suit concerns of institutional competency and appropriateness independently of the terms of the claim on the merits justiciability concerns about requested remedy inappropriately determine justiciability on the substantive arguments about rights protection remedial requests have no place in the determination of whether or not the challenge can proceed to consideration on its merits should an infringement be found then fuller engagement with the range of jurisprudence showcased for example in the intervenor factum of the asper centre on remedy can then be better canvased 119 the minority judgment crafted by feldman ja would find that it was an error of law to strike this claim at the pleadings stage feldman jas judgment begins with the reminder that the test for striking the application at this stage is whether it is plain and obvious that the claim is doomed 120 this requires that as the supreme court of canada notes the claim is certain to 114 tanudjaja onca supra note 3 at para 30 115 this is what the majority does in its concluding claim that it has left unconsidered the question of positive obligations ibid at para 37 116 tanudjaja onca supra note 3 at para 32 117 r v oakes 1986 1 scr 103 53 or 719 118 tanudjaja onca supra note 3 at para 33 119 fail 121 significantly the supreme court has stated that neither length and complexity of the issue nor novelty alone is reason to strike a claim instead the supreme court through the pen of the chief justice has cautioned that the decision to strike must be carefully deployed new and novel developments in the law are standard and many result from actions initially deemed hopeless and initially challenged by preliminary motions to strike 122 consequently t he approach must be generous and err on the side of permitting a novel but arguable claim to proceed to trial 123 the dissent by feldman ja emphasizes these refinements of the test for dismissal issuing the stricture that t he motion to strike should not be used … as a tool to frustrate potential developments in the law 124 the motions judge comes in for specific criticism in relation to this larger concern discussion of the applicants section 7 claim was flawed in four specific ways misstatement of the appellants claim misstatement of section 7 jurisprudence definition of section 7 jurisprudence inappropriate to decisionmaking in a motion to strike and preventing consideration of the full evidentiary record 125 each of these charges is discussed at some length with feldman ja detailing in particular the motion judges extensive doctrinal interpretations and resolutions of law not yet settled that illfit the context of a preliminary motion to dismiss most damning however for feldman ja is the result that the motion judge would leave the 16 volumes of evidentiary record submitted by the appellants unexaminable particularly to the question of whether or not special circumstances exist for inclusion of positive obligations under section 7 126 equally feldman ja notes that the motions judge engaged in fact finding doctrinal exegesis and resolution in his discussion of the applicants section 15 claim in the absence of engagement with the full evidentiary record and in the context of a preliminary motion the motions judges conclusions about causal factors and analogous grounds are faulty such matters are not open for decision when the application is not allowed to proceed 127 in her discussion of the justiciability concern feldman ja takes on her own court of appeal colleagues more directly citing a number of academic authorities she argues that to strike a serious charter application at the pleadings stage on the basis of justiciability is therefore inappropriate 128 more specifically while the novel form of the claim raises some tricky procedural and conceptual difficulties for both the charter argument and remedial stage again feldman ja reminds her colleagues that novelty alone is not a relevant reason for dismissal and that as helpfully underlined by one of the intervenors the question of remedy is distinct and subject to judicial crafting independent of argument pertaining to charter breach 129 feldman ja concludes by reminding her audience that this application represents not only the claims of a broad range of disadvantaged individuals and groups but is backed by a considerable number of credible intervening institutions with much expertise in charter jurisprudence and analysis this larger frame adds weight to her opinion that the housekeeping measure of dismissal for lack of reasonable cause is improperly wielded by the motions judge so why is such common and convincing conceptual parsing beyond the ken of many of our judges clearly something more ideological is at play resort to stale platitudes about positive versus negative rights and misconceived challenges may signal an underlying general anxiety about the redistribution of resources recognition and participation 130 activists push through charter litigation more evocatively these challenges threaten the mythology of … the majestic enduring and selfsustaining neutrality 131 of constitutional law articulation of rightsof any sortinvolves delineation of an imaginary line between public and private regulation and thus to ask the purpose of human rights is always to ask a political question 132 the libratory potential of rights is the unavoidable flip side of coercive potential that is of rights power to impose the public values they enshrine on private and personal orderings the right to housing engages specially with this classical tension between liberty and equality as the right to housing so centrally encompasses that most private spherethe home 133 combatting this political reluctance and its ideological roots is beyond the reach of doctrinal correction and critique but it is appropriately targeted by the charge that judges who assert its mythology unquestioningly must be held responsible for ensuring that social justice under the charter will never amount to much it is not surprising that the attorneys general have pushed motions to dismiss it is a strategic move given the character of the canadian judiciary but it is a strategy that will work to consign canadas constitutional protection of human rights well behind the leaders of global human rights protection the argument this paper seeks to advance is that the character of human rights infringements like denial of access to adequate housing does not fit the tidy boxes of traditionally framed legal challenges this observation flows significantly in part from the early indication of just how complex housing needs across various groups are if we want to be able to scrutinize the multiple and textured way in which the state is implicated in setting the conditions necessary for this crisis and for the maintenance and intensification of the crisis it is important to have within the purview of the court more than singular snippets of government action and inaction equally orders that compel governments to coordinate across a range of programmes and actions may be the answer to providing reasonable remedial response to human rights crises of this fractured sort this is the question the tanudjaja case has handed the courts it would be a shame if these arguments never get their day in court vi conclusion so the tanudjaja application has foundered on the two traditional bogeymen repeatedly thrown up to block socioeconomic rights fears about positive rights and the spectre of nonjusticiability that these hurdles would appear so powerfully in this application is not surprisingthe applicants challenge is an extensive condemnation of current regular government practice it is a parry against business as usual the claim makes visible and gives voice to the many among us whose basic needs go unmet while calling the government to account for this dispossession this is disruptiveas rights at their best are 134 private suffering is rendered public and collective response becomes obligatory 135 consequently the repeated defeat of this application at the stage of a preliminary motion to dismiss is distressing tanudjaja raises such important issues governments duck and weave when confronted politically with the sight and plight of the poorly housed the most so far that insistence on negative obligations under the constitution has achieved are the temporary cardboard box overhead shelters of victoria v adams 136 if litigation under the charter is not allowed to present more than narrow pieces of the problem of housing insecurity at any one time if all the charter can do is stay silent in the face of government inaction and if courts continue to dodge acknowledgement that rights are always already about redistribution then the homeless and other marginalized groups in canadian society are truly constitutionally outside in the cold 134 hohmann supra note 8 at 244 135 ibid at 7 136 adams supra note 10 for discussion of this case see margot young rights the homeless and social change reflections on victoria v adams 80 bc studies 164 martha jackman charter remedies for socioeconomic rights violations sleeping under a box in sharpe roach supra note 90 at 279

this article is brought to you for free and open access by the journals at osgoode digital commons it has been accepted for inclusion in journal of law and social policy by an authorized editor of osgoode digital commons professor faculty of law university of british columbia many thanks to the editors of this journal and to the anonymous reviewers for their thoughtful comments funding for the project was received from the peter wall solutions initiative at the university of british columbia i am grateful also to my very capable research assistants rochelle collette tannis baradziej and malcolm funt

introduction it has long been acknowledged that socioeconomic determinants play an important role in the characterization of climate risks through vulnerability and exposure 1 as a result nearly all assessments of climate risks consider both climatic and socioeconomic conditions 2 nevertheless when it comes to modelling future climaterelated health risks the overwhelming majority of studies have been based on projections of future climatic conditionsthrough climate models and scenariossuperimposed on current socioeconomic conditions only 3 4 5 by making the implicit assumption that drivers of risk other than climate change will remain the same most of the existing studies have failed to account for the influence that socioeconomic development might have on future climaterelated health impacts 6 this crucial issue of temporal scale mismatch was raised more than a decade ago 78 the dynamics of vulnerability have been long recognized 9 and several papers have stressed the need for improved understanding of future vulnerability 14 10 11 12 in spite of this future socioeconomic conditions have been very rarely accounted for until now and projections of human vulnerability are largely lacking 6 given that a large share of climate risk assessments serve adaptation purposes such a practice is likely to introduce systematic bias into climate and health adaptation strategies 3 partly to counteract such shortcomings and to foster the use of socioeconomic scenarios and projections within climate risk assessments the climate change research community has been engaged over the past few years in the development of a new scenario framework in which climate and socioeconomic scenarios were developed in parallel 13 this new scenario framework for climate change research comprises a set of greenhouse gas emissions trajectories namely the representative concentration pathways 14 and a set of global socioeconomic development trends namely the shared socioeconomic pathways 15 these global pathways have been designed to be combined in a scenario matrix architecture 16 assuming that given rcps can be reached by different sspsto explore the wide range of challenges to mitigation and adaptation while much of the climate research has been focused on understanding the impacts of different rcps on a wide array of socioeconomic and natural systems 17 very little has been done until now to explore the influence of temporal dynamics of socioeconomic systemsunder the sspson future human vulnerability and climaterelated health risks 18 in fact despite the rapidly growing array of studies making use of both the rcps and ssps to explore future climaterelated health impacts the influence of changes in socioeconomic conditions is still largely underestimated and mostly constrained to changes in exposure only utterly neglecting the effect of changes in human vulnerability 19 drawing on this the aim of this paper is twofold first it aims to critically discuss the current state of practice in relation to the use of ssps in the assessment of future climaterelated health impacts in order to identify and better characterize the research gaps and needs particularly in terms of availability of socioeconomic projections second through a european casestudy this paper aims to present two innovative methods that complement existing projection methods and have the potential to address the aforementioned research needs current state of practice shared socioeconomic pathwaysssps the ssps are the latest set of ipccguided global socioeconomic development trends that provide a global context to guide climate change research at both global and regional levels 1520 they are made up of five contrasting global development pathways that depict plausible alternative future states of the society and the environment they have been purposely designed to span the wide range of socioeconomic challenges to adaptation and mitigation a substantial body of literature has documented their development 1315 20 21 22 23 24 25 their quantification at the national level up to 2100 for a few key socioeconomic variablesfreely available online 26 such as demography and education 2728 urbanization 29 economic growth 30 31 32 and land use 33 their integration with climate change 34 and their links with future atmospheric concentration of greenhouse gases 35 36 37 38 extended ssps an important feature of the ssps lies in their flexibility they have been purposely conceived to be extended ie contextualized detailed and eventually quantified for specific regions andor sectors 39 extended versions of the global basic ssps have an increased suitability and usefulness for local andor sectoral studies are of greater relevance for policymaking and are more likely to be used by local stakeholders a growing number of studies have employed the narratives of the global ssps to develop extended ssps for specific regions andor sectors so far extended ssps include extended ssps of urban and population development worldwide 4041 in coastal areas 4243 and in large cities 44 extended ssps for health 4546 for the water sector 4748 for fisheries 49 for the forestry sector 50 and for food security worldwide 51 in westafrica 52 and in southeast asia 53 and extended ssps for specific regions eg the barents region 54 the arctic 55 tokyo 56 iberia 57 scotland 57 the us 58 and europe 559 integration within climaterelated health impact assessments the ssps have been purposely designed to be used within impacts adaptation and vulnerability studies therefore they have the potential to enhance the integration of socioeconomic scenarios within futurelooking iav research 3960 and to improve the comparability between different case studies 6162 over the past few years a rapidly growing number of iav studies have made use of the sspscoupled with different rcpsto assess future climaterelated health impacts under multiple combinations of socioeconomic and climate scenarios so far these studies have been conducted in the fields of food security and hunger risks 536369 fire risk 70 exposure to vectorborne diseases 7172 water scarcity 73 74 75 76 77 78 flood risks 79 80 81 air pollution risks 8283 and heatrelated health impacts 84 85 86 87 88 89 90 91 92 93 94 95 96 97 research gaps and needs the aforementioned studies that use ssps and rcps to explore future climaterelated health impacts show a number of recurrent shortcomings which can be translated into research gaps and needs these drawbacks are mainly related to the lack of regional and sectoral contextualization of the global ssps and to the lack of consideration for vulnerability these are detailed below lack of extended ssps a number of existing studies make a straightforward use of the global ssps narratives and of their quantification at the country level without contextualizing them for the region andor sector of interest thus neglecting the processes that are specific to a given region andor sector and that influence future socioeconomic and environmental trends the most common practice linked to this shortcoming is to assume a homogeneous population or economic growth rate within an entire country to downscale national projections of the global ssps at the subnational scale without accounting for local socioeconomic processes that may influence the distribution of population or economic growth within the region for instance marsha et al 92 have applied the global ssps population change rates at the national level to estimate future population growth in houston without considering houstons specific socioeconomic and urban development similarly koutroulis et al 78 and alfieri et al 81 have employed nationallevel quantitative projections of the global ssps in their assessments of future water security and flood risk in europe without accounting for specific european socioeconomic developments 59 another recent example lies in a study 76 in which the authors assumed a similar population growth rate in floodprone areas as the growth rate at the national level despite recognizing that population usually tends to grow faster in floodprone areas than in other places in this particular case such an assumption led to an underestimation of the number of people exposed to river flooding lack of consideration of vulnerability the overwhelming majority of existing assessments of future climaterelated health impacts account only for future exposure under different ssps and neglect the future populations vulnerability such a lack of consideration of vulnerability can be found in most of the existing studies eg in assessment of future heat stress risk 8588909495 of future flooding risk 76 of future risk of vectorborne diseases 71 and so on while most of the aforementioned authors acknowledge that future research should attempt to integrate projections of drivers of human vulnerability these are still very rarely found by disregarding the future states of vulnerability past studies have focused only on the population effect 8895 and have substantially underestimated the influence that varying levels of socioeconomic development may have on future climaterelated health impacts 3 up until now the few studies that have employed projections of vulnerability under the ssps have been limited to projections of age education 86 income level water demand 7578 urbanization 87 crop demand and share of livestock 63 it is also worth noting that most of these projections of drivers of vulnerability have been employed at a very coarse spatial resolutioncountrylevel mainly thus limiting their usefulness for policymaking and their intake by local stakeholders as well as their compatibility with climate projectionsoften realized at 05 • 98 to justify such paucity of contextualization of socioeconomic projections under the ssps and such lack of consideration of future populations vulnerability authors traditionally point out the scarcity of socioeconomic projections in terms of diversity spatial scale consistency with the ssps and relevance at local scale this research gap provides a convincing explanation of the aforementioned drawbacks this close look at the current state of practice clearly highlights the needs to develop quantitative projections of socioeconomic variables that are consistent with the global ssps while accounting for local and sectoral specificities that are produced at relevant spatial and temporal scalesin line with climate models outputs and with the scale at which socioeconomic processes happen and that cover the broad range of drivers that influence human vulnerability to climate change table 1 statements from assessments of future climaterelated health impacts based on ssps and rcpswith in addition one review study and two iav studies that do not make use of the ssps but which reflect typical statements found in the literature these highlights both the need to consider future vulnerability under the ssps and the lack of available projections to do so study statement 92 this study utilized ssp nationallevel demographic and economic projections rather than cityspecific projections of houston because sspbased projections were unavailable for the city the nationallevel ssp projections are likely inaccurate given the citys rapid growth of racially and ethnically diverse populations 84 the health impacts of heat vary by personal susceptibility factors like age and heat effects might be compounded by concurrent exposures like high air pollution or power outages future research could explore whether such characteristics could be projected for future heatwaves with enough resolution to be usefully incorporated into projections 95 our initial exploration of a potentially transformative risk factor for humans only considers population exposure however the impacts of heat on humans depend on both exposure and vulnerability with the latter depending on many other factors including population age degree and type of preexisting health conditions the ssps may offer a means of exploring potentially critical correlations between heat population density vulnerability and the potential for adaptation 85 in this work we only analyzed the change in exposure to extreme heat as a function of a change in the hazard and population to properly estimate a change in risk of mortalitymorbidity resulting from this exposure demographic and socioeconomic characteristics such as age gender per capita income and education level should be included into the analysis however since projections of these characteristics tend to be relatively coarse and of low confidence we have not included the demographic and socioeconomic factors in our analysis 97 finally quantifying exposure is a starting point for estimating future risks but further work is necessary on vulnerability to the impacts of extreme heat including population age structure and income as well as possible changes in social and institutional factors over time which will play important roles in heatrelated impacts 94 ssp3 assumes a fragmented world following varied regional social political and economic pathways this may be considered difficult to reconcile with the international collaborative effort that would be required in order to keep the global temperature from exceeding 15 ºc however we consider it here on the grounds that what applies as a general rule globally does not necessarily need to apply for india itself and that having a population scenario that spans a larger range will allow a more expanded study of the relation between heatwaves national population and mpehwd in future studies we would like to account for more demographic characteristics in addition to growth ie age sex education and income which are likely to be stronger factors for demographic change in the 15 • c target however we currently lack the required sophisticated data 75 we used a simplistic model to estimate industrial and municipal water use progress in this area of modeling has long been obstructed by a lack of data but further efforts are needed the water use scenario that is used significantly affects the results hence further efforts are needed to establish consistent scenarios 74 to come to a full risk assessment framework more work needs to be done to make the transfer from risk estimates in terms of exposed population towards estimates covering economic impacts a first step therein should be to include vulnerability including the sensitivity of a population to water scarcity the available infrastructure and resources to cope with water scarcity and capability of the responsible government to deal with water scarcity in a quick and efficient manner 72 final suggestion related to making better use of the new generation of socioeconomic scenarios it is somewhat ironic that climatic impacts adaptation and vulnerability research which is so dependent upon assumptions about socioeconomic development has tended to underutilize socioeconomic scenarios this is no different for the health sector but there are opportunities to rectify the situation one solution would be for climate change and health researchers to work to extend the ssps so that they have more specific healthrelated variables one key issue is the availability and parameterization of relevant vulnerability indicators within the ssps the availability of highresolution projections for broaderlevel vulnerable indicators such as income distribution population health and governance would be an important starting point 99 it was decided to base adaptive capacity on present day data rather than future projections because it is much harder to obtain future projections of relevant socioeconomic data than it is for climate data the great uncertainty inherent in any socioeconomic projections would contribute to the multiplication of overall model uncertainties 100 although vulnerability is dynamic and changes over time there is no quantitative information available about how this may affect damages hence we assumed no future changes in vulnerability methods to project drivers of human vulnerability in light of the aforementioned research gaps and needs i introduce here several methods that have the potential to address the need for quantitative projections of drivers of human vulnerability consistent with the ssps contextualized and produced at relevant spatial and temporal scales i first briefly discuss the two main approaches that have been applied so far namely the use of sectoral models and the spatial disaggregation of existing projections and then detail two new and innovative methods that can complement the existing approaches these are based on the matching of existing scenario sets to generate consistent projections and on the quantification of experts opinions coupled with correlation analyses these have been recently applied to europe to explore future social vulnerability 5 and future heatrelated health impacts 19 existing methods use of sectoral models until now one of the most common approaches to quantifying the ssps has been the use of sectoral models for instance the global ssps have been quantified for key socioeconomic variables at the national level with sectoral models such as urbanization models 29 demographic models 2728 and economic models 31101 worldwide jones and oneill 40 have employed a gravity modelbased approach to produce spatiallyexplicit projections of population and urbanization patterns at the regional level urbanization and demographic sectoral models have been applied for instance to produce urbanization and population projections under the ssps for the 101 largest cities 44 for the coastal zones 42 for the mediterranean area 43 for europe 102 a few other sectoral models have also been used to projectunder the sspssocioeconomic variables related to water demand and food consumption mainly at the global scale 4769103 it should be noted here that the use of sectoral models to project drivers of human vulnerabilityother than population and urbanizationat the local scale and based on regionalsectoral extensions of the global ssps has yet to be explored spatial disaggregation another fairly common approach to obtaining projections at a relevant spatial scale in iav studies is the spatial disaggregation of existing projections which have been produced at the national scale under the global ssps 26 to disaggregate these nationallevel projections authors traditionally employed current statistics at subnational levelconsidered as the benchmarkand applied countryand sspsspecific growthdecline rates over all the subnational units of a given country ensuring that the relationship between the distance from a given subnational value to the national mean and the distance from the national mean to the minimum and maximum subnational values remain similar to those in the benchmark a few examples of studies that have employed this approach to downscale national projections under the ssps include xing et al 104 who have downscaled projections of population gdp per capita and urban population share under ssp2 for 31 provinces in china marsha et al 92 who have downscaled national projections of gdp and population in the us for each block group of houston city and rohat et al 5 who have downscaled projections of education under ssp1 ssp3 and ssp4 at the nuts2 level for 30 european countries while such a downscaling approach based on current figures is useful to approximate the national projections at a local scale it fails to account for contextspecific characteristics that influence local socioeconomic development trends to account for these local trends the downscaling process of the national projections should be informed by an interpretation of the global ssps assumptions at the local scale or by contextspecific downscaling scenarios in europe hurth et al 105 and lückenkötter et al 106 have downscaled national projections of gdp per capita and population density on the basis of the coupling of the latest scenarios of the european commission directorate general for economic and financial affairs namely the trend and convergence scenarios 107 with current figures of gdp per capita and population density at very high spatial resolution the resulting contextualized and downscaled projections of gdp per capita and population density are available at a very high spatial resolution accounting for the local contextthrough the regionalization with the european scenariosand are consistent with the global ssps national projections such projections have been used in rohat et al 19 and are expected to be integrated within a number of forthcoming european iav studies scenario matching the use of scenarios in environmental studies has substantially increased over the past decades 108 leading to the development of a large number of different scenario sets in europe 109 110 111 112 although their scientific acceptance and their relevance for climaterelated issues may vary 113 these existing scenario sets represent an extremely valuable basis of knowledge regarding the multiple ways the future could unfold and in relation to the impacts of varying levels of socioeconomic development on a range of sectors such as demography urbanization housing economy health land use agriculture transportation and so on 114115 although it has been argued that it would be unwise not to employ such a great source of knowledge 116 the reuse of existing scenario sets in iav studies has been limited until now to the use of their storylines to extend the global ssps narratives 5758117 to my knowledge the quantitative elements of existing scenario sets have never been reused in assessments of future climaterelated health impacts i argue here that the use of existing quantitative projections of previouslydeveloped scenario sets has the potential to address the need for projections of drivers of human vulnerability provided that they are consistent with the ssps the latter consideration is of the utmost importance to ensure the intercompatibility between sspsbased iav studies 39 the consistency between existing scenario sets and the global ssps should be rigorously checked using systematic methods to match the narrative of a given existing scenario with the storyline of a given ssp 50525458 building upon a forthcoming paper 5 i present here the results of a scenario matching approach that was applied to match the global ssps with three european scenario sets namely et2050 demifer and climsave these can be characterized as follows • et2050 comprises four scenarios of territorial development and cohesion in europe 118 that have been quantified for variables related to urbanization accessibility and transport nodes at the subnational level 119 the four scenarios are named baseline megas regions and cities • demifer is made up of five european demographic scenarios 120 that have been quantified for a number of key demographic and lifestyle variables such as labor force ageing employment life expectancy and different types of migration at subnational level 121 the five scenarios are named status quo growing social europe expanding market europe limited social europe and challenged market europe • climsave comprises four crosssectoral european scenarios 122 123 124 that have been quantified for variables related to ecosystems services and provisions and environmental conditions at high spatial resolution 125 the four scenarios are named we are the world icarus riders on the storm and should i stay or should i go employing a systematic scenario matching approach authors identified three different groups of scenariosmade of one scenario of each seteach sharing significantly similar storylines these groups of scenarios are then viewed as extended versions of the ssps which showcase an increased relevance at the european level and for sectors related to human vulnerability compared to the global ssps storylines table 2 groups of scenarios sharing similar storylines matched with the scenario matching approach 5 each group constitutes a given extended ssp group of scenarios global ssps et2050 scenarios demifer scenarios climsave scenarios extssp1 ssp1 b gse ww extssp3 ssp3 base cme ica extssp4 ssp4 a eme rs being made up of a combination of scenariosone from of each of the four scenario setsthe newlycreated extssps can be readily quantified through the couse of the quantitative outputs of each scenario set as an example the quantitative projections made under et2050b demifergse and climsaveww are viewed as consistent with one another and with ssp1because their respective storylines have been matchedand therefore constitute the quantitative part of extssp1 in this way authors were able to readily quantify the three extssps at the subnational level up to 2050 for a wide number of variables related to territorial development and cohesion demography and lifestyle and environment a large proportion of these variables are considered as important determinants of human vulnerability and could therefore be integrated within assessments of future climaterelated health impacts figure 1 and table 3 present a sample of these readily available and spatiallyexplicit quantitative projections in europe under the three extssps experts elicitation and correlation analyses for a certain number of determinants of human vulnerabilityeg those related to health conditions governance efficiency or human behaviorquantitative projections under different socioeconomic scenarios simply do not exist and models are not available or not yet well developed in such cases more simplistic approaches may be considered in order to obtain rough projections under the different ssps this should be preferred to discarding a variable andor assuming fixed conditions particularly if the variable in question is an important driver of vulnerability i present here an innovative approach based on experts elicitation and correlation analyses to quantitatively project two significant determinants of vulnerability to heat stress in europe namely the proportion of elderly people living alone and the prevalence of overweight it has been shown that social isolation among the elderly considerably increases the risk of death during extreme temperatures events 126 127 128 mostly due to their lower access to transportation and their lack of support during heat waves 129130 similarly research has shown that preexisting medical conditions such as overweight lead to significantly higher risk of death during heat waves 126131132 the workflow of this innovative method is presented in figure 2 and each step is detailed below determination of local trends due to the global ssps lack of explicitness regarding future developments in public health conditions and in living arrangements of the elderly i first interpreted the global sspsusing the existing european ssps developed within the impressions project 59117 and the preliminary version of the extended ssps for health 45 to determine future trends in the proportion of the elderly living alone and in the prevalence of overweight under each ssp the interpretation of these existing extended versions of the ssps led to a fairly straightforward establishment of future trends in overweight prevalence in europe as presented in table 4 these were validated by three different experts conversely determining the future trends in the proportion of the elderly living alone was a much less straightforward process as trends in living arrangements are not mentionedeven implicitlyin the european ssps narratives therefore i first conducted a short literature review to identify the main drivers of living arrangements among the elderly in europe 133 134 135 136 with the help of two experts in household composition i identified the following key drivers aging of the population health conditions economic situation type of society and social cohesion in light of these drivers of the elderlys living arrangements i then determined the trends direction under each ssp unlike the trends in future overweight prevalence the trends in future proportions of elderly people living alone were not only determined for the whole europe but also for three different clusters of european countries these clusters were determined based on current figures of the proportion of elderly people living alone with the current proportion being 40 on average in the northern cluster 33 in the centralwestern cluster and 25 in the southern cluster such elicitation of the trends at the subeuropean level allows better accounting for the differential intraeurope development pathways 59 and extended ssps for health eussps citations extracted from the narratives of the european ssps and the healthssps trend in prevalence of overweight in europe eussp1 population health improves significantly increased emphasis on enhancing health and health care functions reduced burden of health outcomes changes in dietary patterns to lower burden of some chronic diseases high investments in human health and education large decrease eussp3 population health decreases significantly countries experience double burden of infectious and chronic climaterelated health outcomes reduced funding for surveillance and monitoring programs low investments in human health and education phasing out of social security system large increase eussp4 unequal world with limited access to high quality education and health services lower burden of some chronic diseases from changes in dietary patterns high investments in human health and education for elites only low for others increase eussp5 world attains human sustainable goals health improves significantly but not as much as in ssp1 because the challenges for local management of environmental quality are larger the burden of chronic diseases is somewhat higher than in ssp1 high investments in human health and education decrease to quantify the aforementioned trends in the proportion of elderly people living alone and in the prevalence of overweight under each european ssp i employed the fuzzy set theory approach based on experts elicitation 137138 in collaboration with a few selected experts i designed two distinct online questionnaires oriented towards health experts and living arrangement experts respectively in each questionnaire experts were first presented with a short description of the four eussps then with trends in the proportion of elderly people living alone under each eussp experts were then asked to give their level of agreement with these trends considering the eussps description given beforehand they were then asked to give a numerical range for each scenario trend of the proportion of elderly people living alone at the subeuropean level these online questionnaires were distributed to 300 european experts in overweight and 420 european experts in living arrangements identified through extensive literature research the response rate approximated 7 for both questionnaires yielding 21 and 29 different answers for the questionnaires on overweight prevalence and on the proportion of elderly living alone respectively based on these experts quantitative views i then determined the center of gravity for each scenario trend 138 figure 3 displays such centers of gravity for the prevalence of overweight these centers of gravity were then translated into adjustment factors ie percentages of increasedecrease compared to the baseline for the period 20152050 these adjustment factors represent the unified experts quantitative view on the future trends of these two socioeconomic variables in europe final projections before producing the final projections of the proportion of elderly people living alone and of the prevalence of overweight i first computed intermediate regional projections employing correlation analyses to do so i relied on existing correlations between the variable to project and other variables for which projections under the ssps already exist eg gdp population and urbanization in the case of overweight prevalence current statistics 139 show that large differences exist across different age groups and urbanization levels based on these correlations at the country level and employing existing projections of population and urbanization under the european sspsproduced at the nuts2 level and on a 10 × 10 km spatial grid respectively 106140 i computed intermediate regional projections of overweight prevalence that account for future changes in population structure and urbanization under each eussps employing the scenariospecific adjustment factors determined by the experts i then computed the final projections of the overweight prevalence under the four eussps while these projections are performed at both nuts2 level and on a 10 × 10 km spatial grid the adjustment factors are assumed to be homogeneous over europe or over each countries cluster it has to be mentioned here that due to the lack of established correlations between the proportion of elderly people living alone and common socioeconomic factors such as gdp population and urbanization no regional intermediate projections of the proportion of elderly people living alone were produced and scenarioand regionspecific adjustment factors were directly applied to the current figures at nuts3 level discussion addressing the research needs the evaluation of the current state of practice clearly highlights the needs to produce quantitative projections of socioeconomic variables that cover the wide range of determinants of human vulnerability to climate change are both consistent with the global ssps and locallyrelevant and are available at relevant spatial resolution in line with climate models outputs and with the scale at which socioeconomic processes take place the two innovative methods presented in this papernamely the scenario matching approach and the approach based on experts elicitation and correlation analysesshowed great potential to address these needs on the one hand the scenario matching approach led to the quantification of a dozen socioeconomic variableslinked to urbanization territorial development demography employment and biodiversityat the subnational scale up to 2050 under three different european ssps the latter are extended versions of the global ssps that account for the local specificities of the european union such projections of drivers of human vulnerability have the potential to be integrated in assessments of future climaterelated health impacts in europe which have so far failed to account for the dynamics of vulnerability 96141142 on the other hand the approach based on experts elicitation and correlation analyses showed that singularbut highly importantdeterminants of human vulnerability such as social isolation and preexisting medical conditions can also be quantitatively projected under the ssps at relevant spatial and temporal scales here i quantified the future proportion of elderly people living alone and the future prevalence of overweight in europe at highspatial resolution under four different european ssps as for the projections obtained with the scenario matching approach these projections can be readily included within assessments of future climaterelated health risks in europe as highlighted in rohat et al 19 in addition to these two innovative approaches which appear to be useful alternatives existing methods to quantify the ssps also show great potential to address the aforementioned research needs to better address these needs spatial disaggregation approaches should ideally be informed by local and contextspecific downscaling assumptions andor scenarios this may enhance the relevance of the outputs for local assessments of climaterelated health impacts similarly in order to produce relevant projections for local iav studies sectoral models inputs should preferably originate from the modelers andor stakeholders interpretation of extended versions of the global ssps rather than from the interpretation of the global ssps which largely lack regional and sectoral details 113138 limitations although the two innovative approaches presented in this paper have the potential to address the iav research needs in terms of spatiallyexplicit local and contextualized projections of the wide variety of drivers of human vulnerabilityconsistent with the ssps framework these are associated with a number of limitations on the one hand the scenario matching approach requires the availability of a number of existing scenario sets that showcase specific characteristics such as detailed narratives that do not contain any assumptions about climate changeso that they can be matched with different rcps afterwardsand freely available quantitative projections of the socioeconomic variables of interest performed at relevant temporal and spatial scales while appropriate scenario sets were easily found at the european level 5 this may not be the case for scenariopoor regions and for studies aiming at matching the ssps with more local scenario sets in addition the scenario matching approach is unlikely to lead to the localsectoral extension and quantification of all the five ssps but rather of a limited number of them it is indeed very unlikely that existing scenario sets would be found to comprise an analogous scenario for each of the five ssps nevertheless bearing in mind that most of the iav studies do not use the five ssps but rather focus on the few ssps that best fit with their research needs 84 such a drawback does not appear to limit the potential applicability of the scenario matching approach in assessments of future climaterelated health impacts on the other hand the approach based on experts elicitation and on correlation analyses makes use of a number of normative judgments and thus provides only rough estimates for instance to produce the projections of overweight prevalence with this approach i assumed that the existing correlations at the national scalebetween overweight prevalence and urbanization as well as between overweight prevalence and age groupswere homogeneous within all the subnational units of a given country and that they will remain the same in the future under all scenarios furthermore i also assumed that the adjustment factorsretrieved from the experts quantitative viewswere homogeneous over europe to account for the potential different regional dynamics across the european countries under each ssp experts should have been asked to quantify the trends for each of the 28 member countries of the european union but this would have inevitably lowered the engagement rate of the experts in addition to these normative judgments the projections of overweight prevalence and of the proportion of elderly people living alone could not have been checked for consistency and compared with other projections as no comparable european scenario exercise was found therefore although they represent the experts quantitative views the accuracy of these projections remains unknown finally although most of the experts showed a high degree of agreement with the trends under each ssps their quantitative interpretation of these trends differed substantially employing a similar approach with different experts is likely to yield different results hence challenging the replicability of such an approach further research is needed to explore the uncertainties associated with the use of different groups of experts and to assess the fitness of the fuzzy set theory to combine their quantitative interpretations in the same vein it is also worth mentioning that the use of different methods will inevitably lead to different projections under the same ssps posing underappreciated problems of consistency 143 and of intercomparability across different studies for instance population projections in europe under the ssps can be chosen from terama et al 102 available at the nuts2 level using a regional urbanization growth model and residential preferences under four different european ssps jones and oneill 40 performed with a gravitybased model and available on a 0125 • grid for the five global ssps and lückenkötter et al 106 realized with the regional downscaling of national projections available for the five global ssps and the two downscaling scenarios on a 01 • spatial grid although such concern of intercomparability between different sets of projections is limited to a few common variables it should be scrutinized and accounted for conclusions following the development of the new scenario framework for climate change research a rapidly growing number of assessments of future climaterelated health impacts are accounting for future socioeconomic conditions under varying levels of socioeconomic development nevertheless as highlighted in this paper throughout the evaluation of the current state of practice the vast majority of these assessments have focused only on future exposure and have failed to account for future populations abilities to prepare for respond to and recover from climatic hazards scrutinizing the research gaps and needs this paper underlined the rapidly emerging demand for projections of socioeconomic variables that are both consistent with the global ssps and linked to the local context ie making use of extended ssps are available at relevant spatial and temporal scales and cover the broad range of drivers that influence human vulnerability to climate change so far such projections are largely lacking while the wellstructured climate modelling community has been engaged in recent decades in the production of highlevel climatic projections the production of socioeconomic projections to inform iav studies has been left aside 18 in this paper i showed that methods to obtain quantitative projections of socioeconomic variables under the ssps at relevant spatialtemporal scales exist and that innovative methods can be developed to complement the existing approaches i presented two innovative approachesnamely the scenario matching approach and an approach based on experts elicitation and correlation analysesthat both use contextualized european ssps and that enable the quantification of a wide range of determinants of human vulnerability drivers in europe at a relevant spatial and temporal scale although associated with a number of caveats these approachescomplemented by existing approachesshow great potential for use by the iav community to enhance the availability of contextualized projections of drivers of human vulnerability under the ssps and overcome the supposed scarcity of relevant socioeconomic projections assessments of future climaterelated health impacts should thus rely on these methods to project and account for future populations vulnerability this way these studies could explore how socioeconomic changes will affect future health risks under different levels of climate change eg 15 • c and 2 • c further research should be conducted to expand the diversity of approaches to produce socioeconomic projections under the ssps and to refine the existing projection methods in particular further research is needed to better interpret and translate the narratives of the ssps into quantitative inputs for sectoral models 138144 bearing in mind that a given ssp can lead to both negative and positive outcomes on different health issues 4696 explore the use of sectoral models developed in other research fields which may provide projections of relevant socioeconomic variables 145 explore the intercomparability of the different projection methods and explore the potential combinations of existing approaches such further research would have the objective of advancing our understanding of future vulnerability patterns so enabling a more accurate assessment of future climaterelated health impacts and the design of more appropriate health adaptation strategies supplementary materials the following are available online at table s1 short narratives of the five shared socioeconomic pathways figure s1 questionnaire distributed to experts in overweight figure s2 questionnaire distributed to experts in household composition figure s3 experts level of agreement with the presented trends

the shared socioeconomic pathways ssps are the new set of alternative futures of societal development that inform global and regional climate change research they have the potential to foster the integration of socioeconomic scenarios within assessments of future climaterelated health impacts to date such assessments have primarily superimposed climate scenarios on current socioeconomic conditions only until now the few assessments of future health risks that employed the ssps have focused on future human exposureie mainly future population patterns neglecting future human vulnerability this paper first explores the research gapsmainly linked to the paucity of available projectionsthat explain such a lack of consideration of human vulnerability under the ssps it then highlights the need for projections of socioeconomic variables covering the wide range of determinants of human vulnerability available at relevant spatial and temporal scales and accounting for local specificities through sectoral and regional extended versions of the global ssps finally this paper presents two innovative methods of obtaining and computing such socioeconomic projections under the sspsnamely the scenario matching approach and an approach based on experts elicitation and correlation analysesand applies them to the case of europe they offer a variety of possibilities for practical application producing projections at subnational level of various drivers of human vulnerability such as demographic and social characteristics urbanization state of the environment infrastructure health status and living arrangements both the innovative approaches presented in this paper and existing methodssuch as the spatial disaggregation of existing projections and the use of sectoral modelsshow great potential to enhance the availability of relevant projections of determinants of human vulnerability assessments of future climaterelated health impacts should thus rely on these methods to account for future human vulnerabilityunder varying levels of socioeconomic developmentand to explore its influence on future health risks under different degrees of climate change

background the management of health care for people with chronic illness is a time consuming business for both patients and carers it is usually carried out in the home or from the home and is largely invisible to institutional health care providers the serious and continuing illness policy and practice study undertook qualitative research with people living with chronic illness to understand their experiences and interactions with the australian health system 1 the study sample consisted of people diagnosed with or caring for someone with type 2 diabetes mellitus chronic heart failure andor chronic obstructive pulmonary disease one of the findings that emerged was that both patients and informal carers described experiencing a significant time burden due to managing chronic illness they reported a constant sense of having to juggle the commitments in their lives and saw the demands of managing health related activities as a key element in that struggle the idea of illness work carried out by people with chronic illness has been a key concept in the literature since corbin and strauss 2 foundational qualitative study the three types of illness work they identified include 1 regimen work crisis prevention and management symptom management and diagnosticrelated work 2 everyday life work that includes practical tasks that keep the household going and 3 biographical tasks that are done as the person and their family reconceptualise and reconstruct the story about their lives this concept identifies work domains of people affected by chronic illness but does not identify specific hra undertaken or how much time people spend on doing them information about the time demands of health management have implications for many life areas such as patient or carer capacity to stay in the workforce to manage family and social activities or to maintain usual domestic and personal activities determining their time use may assist health providers to coordinate and manage formal care in a way that optimises time use for both health care providers and health care receivers information concerning health and about time use is sought through national surveys of many countries as can be seen from the data base of time use surveys held by the multinational time use survey at the centre for time use research in the uk 3 however the health data tend to be reported in aggregate with other activities or are general rather than specific the australian bureau of statistics runs a number of national surveys that include questions on health caring and time use the australian time use survey 4 asks respondents to complete diaries about time and includes as health activity personal medical care rest because of illness and health treatments health care in the abs disability ageing and carers survey includes foot care and other tasks such as taking medication or administering injections dressing wounds using medical machinery and manipulating muscles or limbs statistics canada in their general social survey time use utilise a diary to record personal medical care but do not provide a detailed definition of the specific activities included the uk household survey similarly uses a diary to identify activity undertaken at multiple points in time but does not specify on its public website how activities are coded this review aims to summarize the current literature that 1 specifies hra undertaken by people with chronic illness and their informal carers and 2 quantifies the time spent or required to carry out hra methods a scoping literature review was undertaken during january to may 2011 scoping reviews are useful studies that summarise what is known on a specific topic and are often followed by systematic literature reviews 5 in this scoping review literature has been collected evaluated and presented according to methods laid out for rapid review by arksey and omalley 4 both qualitative and quantitative studies have been included for review we conducted an electronic literature search of peerreviewed englishlanguage articles in the medline cinahl and pubmed databases which contained the desired terms in the title abstract or key words furthermore two journals sociology of health and illness and time and society were handsearched in order to locate relevant articles not catalogued in the databases the following search terms and derivatives were used chronic and time and treatmentmanagement and consumerpatientcarer and health the full set of terms and derivatives are shown in table 1 we decided to use the terms chronic illness and chronic disease rather than long term conditions to provide a specific focus on hra linked to chronic illness in addition we included the specific illnesses of diabetes heart disease and chronic obstructive pulmonary disease as they were sentinel diseases in our main study as illustrated in figure 1 searches identified 29 items in cinahl 544 items in medline 14 items in pubmed 210 items in sociology of health illness and zero items in time society twentyone duplicated items were identified leaving 776 unique references two stages of screening were used to identify those studies that matched the inclusion and exclusion criteria shown in figure 1 using and extending the abs definition of personal medical care we looked for activity that would meet that definition in addition to activity related to contact with noninpatient health services hra were included if they were carried out by an individual with a chronic illness or a carer and as stated above were concerned with personal health care including monitoring managementtreatment or directed to activities undertaken to support health including travel to and attendance at health services articles were excluded if they dealt with health professional rather than health service user time or where no specific activities or times were included from the 776 articles identified in the database and journal searches only 6 articles met the inclusion criteria of those excluded almost all addressed either hra or time but without providing both specific activity and specific time one article addressed health professional time rather than patientcarer time a further 25 articles were identified by bibliography and citationsearches of the 6 included articles from which a further 16 articles met the inclusion criteria we selected a final set of 22 articles for full review all authors were engaged at each stage of the design and conduct of the review each search was run by all reviewers to ensure consistency and certainty of data extraction since fewer articles were identified than we expected articles which met the inclusion criteria were read by all three reviewers before being included for review articles included for review were analysed for emerging themes we manually extracted details of the time use measures having read all 22 papers in detail we identified three principle themes 1 time spent by individuals on specific hra 2 time spent by carers on specific hra and 3 the methodological difficulties associated with time use studies where studies reported time spent in hours such as 143 hours we have taken this to mean one hour and 43 minutes rather than one hour plus 043 of an hour we have used the same convention when the time is reported in minutes so that 1902 minutes means 19 minutes and 2 seconds results study characteristics table 2 and table 3 detail the scope of reviewed articles study characteristics are outlined in table 3 studies were conducted in five countries with almost half the articles reporting studies from the united states of america twelve studies provided information about time use or time management among patients six studies reported carer time use only 6 7 8 9 10 11 and two articles concerned time use of both patients and carers 212 most studies reported either survey data or qualitative data four articles focused on methodological issues associated with measuring time use by carers 11 12 13 14 but none focused on methodological issues associated with measuring time use exclusively by patients time spent by individuals on specific health related activities two studies provided information about how much time people spend on certain private or household tasks such as sleeping leisure grooming and on hra including exercise which was reported as a separate item 1516 three articles reported time use in terms of patient compliance and adherence mccoy notes a broad range of potential reasons for noncompliance with selfcare and medication regimens 17 they conclude that medication adherence by people with chronic illness is complex and labourintensive 17 russell et al conclude that factors other than knowledge are needed to achieve necessary behavioural change and compliance however scant attention has been paid to time requirements and little is known about how much time current recommendations take 18 53 see also 19 the most comprehensive information about actual time spent on hra was found in studies based on the usa bureau of labour statistics american time use surveys these surveys provide a comprehensive set of statistical data russell 20 reports that for the 113 of adult americans surveyed who indicated that they had spent time on hra in the previous 24 hour period the average time spent overall was 108 minutes those engaging in personal health selfcare reported it to take an average of 86 minutes medical and care services reportedly took 123 minutes and sports exercise and recreation reportedly took 114 minutes those caring for others reported spending between 78 and 115 minutes in activities related to the health of others this contrasts with the findings of mckenna and colleagues 21 in an australian qualitative study comparing people who had suffered a stroke with those who had not that hra was the least time consuming of their measured activities and the average time spent was around 30 minutes each day two studies identified time spent attending health service appointments russell et al 22 reported on three years of the american time use survey data showing that of 1621 patients seeking medical care on a designated day mean time spent was 35 minutes for travel 42 minutes for waiting and 74 minutes for receiving services accompanying carers spent an average of 124 minutes for each encounter yabroff et al 23 estimated patient time costs associated with colorectal cancer care using data from several surveys and physicianreported time data they estimated that each office visit required 143 hours or 1 hour 43 minutes for patients in metropolitan areas and 1 hour 58 minutes for those living outside metropolitan areas yabroff et al 23 cite other instances of time measurement associated with screening activity one study hu reuben 24 focused on the length of time elderly patients spent with physicians during ambulatory visits and reported an average of 1902 minutes for elderly patients 27 minutes for new patients and 1803 minutes for established patients concluding that the effects of managed care on the duration of visits appear to be related to the structure of the managed care plan pritchard 25 also focused on consultation times and how patients and gps negotiated and managed this time use but did not specify the time actually spent two studies examined the additional time spent on hra due to diabetes over and above the time people would usually spend on hra using surveys and phone interviews ettner et al 26 studied the impact of socioeconomic status on time spent on self care for people with diabetes looking specifically at time spent on foot care shopping for and cooking special foods and undertaking recommended exercise ettner et al found that those spending extra time on hra as a result of having diabetes spent on average an extra 1341 minutes daily on foot care 3857 minutes on exercise and 4242 minutes on shopping and cooking about two thirds of ettner et als respondents spent extra time on foot care and exercise and about half spent time on shopping and preparing food specifically for their health condition safford et al 19 also used surveys to identify hra of patients with diabetes they report similar findings to ettner et al with 75 of patients spending at least 19 minutes daily on selfmanagement the focus of their discussion is on how many patients did not spend time on specific recommended activities only two studies estimated the overall time required for hra over a 24 hour period russell et al 18 used a convenience group to establish that the time required for self care of diabetes was approximately 120 minutes daily safford 19 quantified how much time diabetics spent on self care with a mean time of 58 minutes per day these included foot care exercise and food shopping and preparation behavioral selfmanagement in patients with hypertension 2010 31 participating in the studys 3 interventions medical costs were estimated using electronic data representing medical services delivered within the health system interventionrelated costs were derived using information collected during the trial administrative records and published unit costs 17 russell minutes safford also identified that over a third of respondents spent no time on either foot care or exercise and over half spent no time on food shopping and preparation in summary studies included for review suggest that over a 24 hour period patients are likely to spend 86 minutes on hra 20 less time if they have had a stroke 21 more time if they have diabetes 181926 if patients also engage in exercise they spend in the order of 35 minutes each day those who care for someone else spend an extra 78 to 115 minutes daily 20 access to health services is not a daily occurrence for most but each event may require between 104 minutes and 151 minutes which includes 35 minutes for travel to health services 42 minutes for waiting for health services and 74 minutes receiving health services 22 if the patient lives in a metropolitan area yabroff suggests the time to access health services is 103 minutes 23 so if a patient with diabetes engages in hra and also accesses health services on a given day they may spend 306 minutes doing so if they also care for someone else on that day their care duties could consume another 78114 minutes a total of almost 7 hours combined these studies present a picture of high time expenditure on daily hra for those with diabetes consistent definition is lacking about the specific tasks carried out by people in managing their health as is the time taken every day or over longer periods to do them in addition apart from estimates of time needed for care of diabetes there is almost no information available about the time costs of health management for people with other chronic conditions and no information concerning time use of people with multiple conditions time spent by carers on health related activities a third of the articles included for review approached time use specifically from a carers perspective 6 7 8 9 10 or in combination with patients 220 a further two papers 2728 provided characteristics or profiles of carers but did not report their time use none of these articles specified the hra carried out or provide specific measures of carer time spent on hra for self only one paper reported carer time spent on hra for care recipient 20 russell et al 20 used atus data to measure time use among american adults and found that people reported spending 78115 minutes per day on hra in support of both household and nonhousehold members bittman thomson 11 and bittman et al 1213 found the abs disability ageing and carers survey and time use survey contained limited and problematic information about the time devoted to care the broad abs categories include meal preparation property maintenance housework transport paperwork health care cognition or emotion communication and mobility but the data provide no details of what some of these may involve nor how much time is spent for each except with cross tabulations with other variables such as carers and care recipients age group disability level or years of care provided at best revealing an average weekly range of 6 to 27 hours climbing to over 105 hours depending on the severity of disability consequently there is hardly any systematic knowledge about what determines the quantity of labour required for informal care its nature or its intensity and the demands it places on families therefore it is not possible to estimate the demands placed on carers how they vary according to changes in circumstances and to make informed judgements about the supply of caring labour 13 57 langa et al 9 report that individuals with chronic lung disease and activity limitations received an additional 51 hwk of informal care compared to those with no lung disease and therefore if the full societal costs of chronic lung disease are to be calculated then the costs to families and society must be accounted for discussion comparison limitations of studies included for review studies included in this review reported encountering multiple methodological difficulties that limited their capacity to comprehensively measure total time use for patients or carers key limitations of the studies included in this review concern secondary analysis mode of time measurement values attributed to time and the lack of consistency in what is measured across studies studies that undertook secondary analysis of large datasets were unable to report detailed information on the elements of hra because they were not included in the survey questions as an example the australian national health survey records activities undertaken by people with selfreported conditions but does not identify what time is taken to carry out any of these activities 29 similarly the australian time use survey how australians use their time 2006 30 identifies health as one of the activities on which time is spent but does not specify or quantify particular activities or the time taken studies were also limited by their mode of time measurement bittman et al 13 examined two data sets on time use from the australian bureau of statistics that utilized two different methods they argue there is an inconsistency in the two estimates and this may be because of methodological reasons such as the time use data may well miss out some supervisory time and not always indicate the extent to which carers rearrange their schedules to be nearby to the care recipient in case they are needed 13 62 regardless of which mode of time measurement is utilised by a study there are likely to be aspects of time use which for whatever reason are not captured with regards to the studies included in this review this limitation does not reflect the quality of research undertaken as much as the complex nature of defining and measuring time use the reviewed studies presented different classifications of time use underestimation of patient time costs may result from misclassification for example bittman et al 12 report that food preparation and cooking may be underreported or classified as a domestic activity rather than a caring task in other cases there may be incomplete information on travel or service time as well as counting multiple therapeutic claims or procedures within a short period as one episode and in monetary terms the extrapolation of the wage rates used in the computation of the value of patientcosts take no account of how sick or retired persons may value their time consumption this is evident in reed et als 31 paper that compared three forms of care for hypertension valuing the patients time based on information from the usa bureau of labor statistics they showed that the three interventions were costadditive to the healthcare system that patients time costs were not trivial and the interventions took no account of how time was valued by patients extending on this problem of classification subjective terminology was used in some time use surveys jenkins 8 identifies several limitations of question styles employed in the 1988 national survey of families and households such as the restrictions created by respondents being asked if they care for someone who is seriously ill or disabled seriously is a somewhat subjective term and all data concerning care recipients which was not deemed seriously ill by respondents was therefore not measured mckenna et al 21 in their study of time use after stroke excluded people from participating if they had cognitive impairment however they note that as cognitive impairment is a result of stroke in 60 of cases this somewhat limited the generalisability of their data similarly bittman and thompson 11 note that the australian bureau of statistics data does not separate caring for disabledhandicapped from caring for chronically ill people limiting the specificity of bittman and thompsons time use analysis other methodological limitations noted in the literature were concerned with whether or not studies were longitudinal or crosssectional 23 or if they compared time use amongst those with and without chronic illness 32 schoefield et al 28 note that time use studies are often based on small samples reducing the power of the findings folbre argues that small time use studies may be gender or otherwise biased discussion of findings this review set out to establish from existing literature which hra undertaken by patients and informal carers has been measured and how much time they are reported to have spent on hra the kinds of hra that are measured and reported in the reviewed studies have limited alignment with the illness work outlined by corbin and strauss 2 some studies did measure exercise and access to health services which could be seen as part of the first kind of illness work which is regimen and diagnostic related activity others looked broadly at hra which is the everyday life work described as the second kind of illness work however in these papers time spent on specific hra was seldom reported diabetes care work was measured by two studies and others included medication adherence other types of hra such as food preparation and consumption or obtaining medicine prescriptions were not reported specifically the biographical tasks outlined in the third kind of illness work did not have a strong presence in the studies although mccoy 17 and paoletti 10 make a start it is likely that studies focusing on the biographical tasks of illness work do exist but did not meet our inclusion criteria such papers could inform researchers of specific hra that are not currently measured there are only a small number of studies which reported patient and carer time use in relation to chronic illness five key articles 611181926 detail that time use and how it affects lifestyle and wellbeing armstrong 33 observed that there is a lack of accurate and comprehensive information about the time spent by people who themselves have a chronic illness in looking after their health it is a point emphasized by singleton 34 692 who says that the voices of patients are disturbingly absent from the literature on time use and which is addressed only superficially by for example corbin strauss 2 mccoy 17 and paoletti 10 this review identified a small number of articles which when combined lead us to conclude that these observations by armstrong singleton and others remain the case these limitations notwithstanding the available literature indicates that the time use and burden associated with managing a chronic illness is sizable 122331 patients with chronic illness and informal carers may be spending 2 hours a day or more on hra measurements of time spent on specific activities are needed to inform our understanding of the real time burden associated with illness work additionally the available literature indicates that approximately 2 hours are required for every health system contact to which can be added the same amount for the time of a carer accompanying the patient these estimates of time spent on hra are likely to under represent actual patient and informal carer time use and as yabroff suggests may increase with progression of the illness if time were consumed in one block it might be more readily accommodated into a persons life style however hra are often spread across a whole day and therefore may be found to be simply disruptive a burden and demotivating as mccoy 17 has demonstrated for hivinfected persons additionally we know almost nothing of how much illnessrelated time burden impacts peoples overall wellbeing motivation and even access to medical care conclusion this review shows that little is reported about the specific activities undertaken by patients and carers to manage chronic illness the results suggest that patients with chronic illness and informal carers may be spending 2 hours a day or more on hra for specific chronic illnesses such as diabetes for which some estimates of time use exist time use may be higher more precise and rigorous measurement of activities and commensurate time commitments with which carers and the chronically ill engage are necessary to better understand the work of chronic illness its impact on life choices and its true cost competing interests the authors declare no competing interests the funding organisation had no role in the study design data collection analysis and interpretation or the writing and publication of this article authors contributions tj made substantial contributions to conception and design acquisition of data primary analysis and interpretation of data and was heavily involved in drafting the manuscript and revising it critically for important intellectual content ly conceived of the study made substantial contributions to conception and design undertook primary analysis and interpretation of data and was heavily involved in revising the manuscript critically for important intellectual content pm contributed to acquisition of data analysis and interpretation of data and was involved in initial drafting stages of the manuscript all authors read and approved the final version of the manuscript authors information

background the management of health care particularly for people with chronic conditions combines the activities of health professionals patients informal carers and social networks that support them understanding the nonprofessional roles in health management requires information about the health related activities hra that are undertaken by patients and informal carers this understanding allows management planning that incorporates the capacity of patients and informal carers as well as identifying the particular skills knowledge and technical support that are necessary this review was undertaken to identify how much time people with chronic illness and their informal carers spend on hra methods literature searches of three electronic databases cinahl medline and pubmed and two journals time and society sociology of health and illness were carried out in 2011 using the following search terms and derivatives chronic illness and time and consumer or carer the search was aimed at finding studies of time spent on hra a scoping literature review method was utilised results twentytwo peer reviewed articles published between 1990 and 2010 were included for review the review identified limited but specific studies about time use by people with a chronic illness andor their carers while illness work was seen as demanding few studies combined inquiry about both defined tasks and defined time use it also identified methodological issues such as consistency of definition and data collection methods which remain unresolved conclusions while hra are seen as demanding by people doing them few studies have measured actual time taken to carry out a comprehensive range of hra the results of this review suggest that both patients with chronic illness and informal carers may be spending 2 hours a day or more on hra illnesses such as diabetes may be associated with higher time use more empirical research is needed to understand the time demands of selfmanagement particularly for those affected by chronic illness

introduction in this study we use modern test theory to evaluate the construct validity of a global scale for workplace social capital based on the operationalization introduced in the third version of the copenhagen psychosocial questionnaire copsoq iii 1 the nordic labor markets are characterized by a high degree of unionization density and a tradition of employer and union collaboration on work environment issues 2 typically workplaces in the nordic countries employ participatory approaches and managerial support for a healthy work environment rather than a conflict culture 3 workrelated stress and health complaints remain an internationally unresolved issue 4 this applies also to the nordic context even though stress is problematic from the perspective of both the individual and the organizations in the national swedish work environment survey from 2015 half of the employees reported too high a work load and four out of ten found their work situation mentally distressing these problems were most pronounced among human service workers 5 in 2016 new provisions were introduced in sweden in order to improve the handling of occupational safety and health at workplaces by means of a more holistic and comprehensive approach addressing the organizational and social work environment 6 another initiative was the establishment of the governmental trust delegation 7 with an overall aim of promoting trustbased organizational development in municipalities and projects including the total governance process this swedish reorientation is in line with the growing attention paid to addressing upstream factors of work life and including perspectives from positive occupational psychology in the nordic countries in general 8 however according to saksvik et al there is a strong need for organizationallevel social relations to be defined and measured as workplace norms 9 in sum this makes social capital an important concept to measure as a workplace characteristic rather than an individual characteristic social capital was introduced in the social sciences in the mideighties in his seminal work bowling alone 13 putnam reflects on american society and notes an erosion of social capital understood as features of social organization such as networks norms and social trust that facilitate coordination and cooperation for mutual benefit putnam describes trends of declining social connectedness civic engagement and civic trust in social life and wonders whether there is an equilibrium of social capital where it develops in other domains of everyday life such as at workplaces a decade later at the beginning of the new millennium nordic work life researchers picked up the thread and introduced social capital as a useful concept in a workplace context questionnaire items covering workplace social capital were developed and in 200405 they were integrated in the danish national work environment survey that led to establishment of the second version of the copenhagen psychosocial questionnaire copsoq ii 19 the items regarding workplace social capital covered aspects of trust and justice and were inspired by researchers in the field including colleagues from finland 19 20 21 22 the latest danish psychosocial questionnaire has likewise included social capital 23 operationalization of workplace social capital by the copsoq instrument workplace social capital has been operationalized based on copsoq ii in a number of studies in order to gain an overview we conducted a literature search and identified 13 articlespublished in international peerreviewed journalswhich have all operationalized social capital by copsoq ii for analytical purposes the search was conducted on june 1 2018 using the string copsoq and social capital in google scholar the search was replicated in pubmed and scopus without yielding additional hits the overview presented in table 1 reveals that the core of the measurement across studies is based on combinations of trust and justice items the items belonging to the trust and justice scales were specifically designed to catch a broader perspective than the individuals own perspective 19 the validity of measurement of workplace social capital as a group construct was further corroborated by cognitive interview results 24 one research group has chosen to replace the entire justice dimension with a scale for rewards which basically asks about the respondents individual perception of being recognized respected and treated fairly at work rather than addressing work climate 9 in addition to trust and justice the scale for community at work is frequently included in particular the item sw2 addressing whether there is good cooperation between colleagues at work additionally three of the research groups have chosen to further include items from other scales or instruments the majority of the articles were published during 201618 which can be seen as a further indication of a growing interest in including the construct in work life research the third version of the copsoq instrument presents a domain for workplace social capital which includes the scales for vertical trust horizontal trust and organizational justice 1 the domain is in accordance with the core of previous operationalizations as presented here workplace social capital is a latent construct meaning that it is not directly observable and therefore cannot be measured directly a latent construct is measured through indicators that represent the underlying construct consequently it is more complicated to measure in a reliable and valid way than directly observable variables operationalization of latent constructs relies on theories and multiitem questionnaires are often used to capture the underlying construct which is considered to be the cause of the item responses before it was launched the copsoq ii instrument was validated in a number of ways and presented in a theme issue of scandinavian journal of public health 2010 in addition to classical test theory methods modern test theory such as differential item functioning was also used although not for the social capital scales 37 in a note from 2011 pejtersen bjo ¨rner and hasle from the national research centre for the working environment denmark reported results on psychometrics of measures of workplace social capital based on the scales for vertical trust horizontal trust justice and respect and items regarding organizational citizenship behaviour 38 however this work was not further developed for international publication consequently the only validation study published on workplace social capital operationalized by the copsoq instrument so far is the qualitative study corroborating the content validity of the items on trust and justice 24 usually in multiitem questionnaires each item has a set of several mutually exclusive response options that can be classified as ordinal variables ordinal variables are numerically coded showing frequency magnitude etc so that responses can be ordered from lowest to highest however the distances between the response categories are unknown thus these values do not have the mathematical properties needed for arithmetic calculations interval scales on the other hand ascribe hierarchy and denote numerical differences that reflect the differences between the objects the intervals between each value on an interval scale are equal once a questionnaire is constructed the soundness of data the collected by means of questionnaires is judged by the measurement properties ie validity and reliability validity refers to the ability of an instrument to measure what it is intended to measure while reliability can be understood as accuracy or the extent to which repeated measurements lead to similar results a standard procedure for handling data from questionnaires is to construct a global score based on the item responses to represent a latent construct unidimensionality is a prerequisite for combining the items into a single global score calculating the mean values of the item responses is a very common procedure however due to the nonmetric properties of ordinal data this procedure should not be taken for granted an important aspect of validation is the adequacy of the scaling of scores which can be done by modern psychometric techniques such as rasch analysis 39 the aim of the present paper is to use rasch analysis to examine the internal construct validity of a global scale for workplace social capital based on copsoq iii items material and methods study design and population the present paper is based on crosssectional data collected during the period from november 2016 to october 2017 as part of a validation and development project for the use of the copsoq instrument at workplaces workplaces were offered a free anonymous work environment survey through the swedish copsoq webpage based at malmo ¨university all staff members at the workplaces received a link to an online questionnaire in an email with an introduction from the workplace itself and information about the research project each survey was open 34 weeks and included two reminders the overall response rate for the convenient sample of workplaces included in the present study was 834 for the purpose of the present study we considered data from 1426 employees from 10 public and private human service organizations inclusion criteria were nonmanagerial employees stating that they have direct contact with patients clients pupils etc as part of their job and with a job title indicating human service work only employees with complete data on all variables included in the present study were considered for the analyses which resulted in 1316 employees being available for evaluation of differential item functioning in a rasch analysis the groups compared should be of approximately equal size 40 the rationale behind this recommendation is to ensure that if there is dif one group does not dominate in the estimates of parameters consequently to achieve a balanced data set in terms of age age was dichotomized into two groups up to 44 years and 45 years or more to obtain a balanced data set with respect to gender all 211 men were included and 211 women were randomly sampled out of a total 1105 women with complete data thus in the present study 422 individuals were included this sample size is large enough to give a high degree of precision ie item location estimates within 03 logits with 99 confidence for the rasch analysis 41 for the sample 54 of the employees were up to 44 years old and 46 were 45 or older and the vast majority of employees were professionals group 2 measures workplace social capital was measured by items from the scales for vertical trust horizontal trust and organizational justice based on the international middle long version of the copsoq iii 1 all six items had the following response options to a very small extent to a small extent somewhat to a large extent to a very large extent for analytical purposes each item was coded 0255075100 following the standard copsoq scoring 1 the items are based on three subscales of which two deal with trust in work relations and one with organizational justice our a priori expectation was that this could be reflected in the dimensionality and in the mutual hierarchy of items according to holtz 42 and colquitt and rodell 43 the tradition in management research has been to regard trust as an outcome of justice drawing on for example social exchange theory 44 or fairness heuristics theory 45 however such a simple causal order can be questioned as argued by shapiro and kirkman who introduced the principle of anticipatory justice 46 recent organizational and psychological experimental studies corroborate that trust can shape the expectations of justice 4748 based on this line of research our a priori expectation was that the item on mutual trust among employees would be endorsed most easily followed by the items regarding vertical trust and that the organizational justice items would be the highest ordered in the mutual hierarchy this follows a reasoning that people can have a sense of whether relationships are characterized by trust independently of concrete experiences while the copsoq iii items regarding organizational justice ask more directly about the handling of potentially problematic situations table 2 overview of items item wording in english wording in swedish tm1 does the management trust the employees to do their work well litar ledningen på att medarbetarna go ¨r ett bra jobb tmx2 can the employees trust the information that comes from the management kan medarbetarna lita på den information som kommer från ledningen tm4 are the employees able to express their views and feelings a ¨r det mo ¨jligt fo ¨r medarbetarna att uttrycka sina åsikter och ka ¨nslor the rasch model and data analysis we tested whether the data fitted the rasch measuring model 39 the model is applied in the development and evaluation of measurement properties of multiitem questionnaires the purpose is to provide a global score that is a sufficient statistic for the latent construct that is being measured by the questionnaire according to rasch latent constructs measured by the questionnaire should have properties analogous with physical measurements with positive real numbers defined as regularly as the measurement of height and not through some arbitrary grading scale in this way fundamental or objective measurement can be achieved an important property of fundamental measurement is that it allows for arithmetic operations such as addition and subtraction the rasch model operationalizes the axioms of additive conjoint measurements which are the requirements for the fundamental measurement construction 49 50 51 52 the process of a rasch analysis is concerned with whether or not the data meets the model expectations the adequacy of the fit is evaluated by means of multiple tests of summary fit statistics individual item and person statistics as well as graphical examinations of fit in the present study the data were fitted to the rasch measurement model using the unrestricted or partial credit model for polytomous cases which allows the distances between thresholds to vary across the items 5354 a threshold is the point between any two adjacent categories in which the probability of either response is equally likely data were fitted to the rasch model using the rumm2030 software 55 assumptions of unidimensionality monotonicity local dependence and differential item functioning were tested briefly explained below 56 the overall fit to the model was evaluated by the itemtrait interaction and mean person and item fit residuals the itemtrait interaction statistic tests the property of invariance across the latent trait and a significant value indicates that the hierarchical ordering of the items varies across the latent continuum the mean person and item fit residuals are expected to be close to zero with a standard deviation of one a nonsignificant value of the χ 2 statistic reflects the property of invariance across the trait the invariance criterion implies that the items need to work in the same way across the whole continuum of the latent construct for all individuals given the same level of the latent trait the scale should also function in the same way for all comparable groups this is commonly known as no differential item functioning monotonicity implies that the item responses are positively related to the latent variable the response structure required by the rasch model is a stochastically consistent item order ie a probabilistic guttman pattern 57 this means that persons who experience higher levels of workplace social capital are expected to get higher scores whereas persons with lower levels of workplace social capital are expected to get lower scores the intended increasing level of workplace social capital across the response categories for each item needs to be reflected in the observed data the reliability of the scale is reported as a person separation index ie the proportion of true variance to true and error variance values of 07 and 09 are indicative of sufficient reliability for group and individual use respectively 58 local dependency was investigated by residual correlations 59 the trait dependency violated the assumption of unidimensionality which was tested by smiths test of unidimensionality 60 for this test first principal component analysis on residuals was performed then items loading positively and negatively on the first principal component of the residuals are used to make independent person estimates next independent ttests for the differences in these estimates for each persons were performed 60 less than 5 of such tests outside the range of 196 to 196 supports the unidimensionality of the scale a 95 binomial confidence interval of proportions 61 was used to show that the lower limit of the observed proportion was below the 5 level 60 possible local dependency can be accounted for by combining correlated items into testlets where the items are added together and then comparing the model fit with that provided by the initial analysis 62 besides overall fit individual item fit was evaluated by items χ 2 statistic the items ability to discriminate the appropriateness of the response categories response dependency relative to other items 63 and the absence of dif for gender and age dif was tested by conducting anova of standardized residuals the disordering of the thresholds was examined graphically by plotting category probability curves disordering of the thresholds was tested by the hybrid approach proposed by salzberger 64 evaluation of the targeting ie the distribution on a logit scale of the items and persons in the sample was examined graphically by a person item threshold distribution graph for a welltargeted instrument the mean location for persons would be around the value of zero in the event of good fit rasch person estimates which are logits can be transformed into a convenient range 65 data is available from appendices 12 results the frequency distribution for each item is presented in table 3 for all items the majority of the responses were concentrated in the categories somewhat and to a large extent while the lowest response category was rarely used initially the rasch analysis was performed on all six workplace social capital items the summary fit statistics of the initial analysis are shown in table 4 analysis 1 the fit to the model was good according to nonsignificant χ 2 statistic the psi value was 083 which is above the predefined criterion of 07 valid for group comparisons item and person fit residual values were somewhat higher than the ideal values shown at the bottom of the table with respect to individual item fit all items besides tm4 had item fit residual values within the predefined optimal range of ±25 and a nonsignificant chisquare statistic the fit residual value for item tm4 was 323 although this was not statistically significant in addition item locations in hierarchical order are shown in table 5 no items showed dif for gender or age high residual correlations were not observed for any pair of the items two items had disordered thresholds ie indicating that it may be difficult for respondents to distinguish between response categories as seen in fig 1 showing category probability curves for item tm4 disordering was observed for the first two thresholds the same pattern was observed for ju1 disordering of the thresholds was not significant according to salzbergers hybrid approach to rule out the possibility of disordering due to the few observations in the lowest response categories an additional sensitivity analysis was performed by rerunning the analysis on the original sample of 1316 participants in that analysis tm4 and ju1 had ordered thresholds the pca conducted on item residuals revealed that the three tm items loaded positively on the first principal component while the reverse was true for the items te3 ju1 and ju4 these two groups of items were then used to perform smiths test of unidimensionality which revealed problems with local dependency as the lower ci was 64 an attempt to resolve this issue was done by performing an additional analysis by combining the positively and negatively loaded items into two testlets as seen by the summary fit statistics fit to the rasch model was achieved accounting for local dependency by testlets resulted in a decreased psi value additional sensitivity analysis was done by performing the rasch analysis on the entire sample and the results were similar the summary fit table for this analysis is found in appendix 3 the distribution of the items and persons along the common logit scale is shown in fig 2 indicating satisfactory targeting although the mean of the persons was higher than the mean of the items ordinaltointerval conversion table given the fit to the rasch model ordinal scores are transformed into intervallevel scores intervallevel scores from the rasch model are on the logit scale which can take both negative and positive values with higher scores indicating higher levels of workplace social capital these logits scores are then transformed into a 0100 interval which is a more familiar range for copsoq users table 6 provides interval scores in both logit unit and in a 0100 range that allows users of the workplace social capital scale to convert ordinal mean score into intervallevel scores ranging 0100 researchers and practitioners who have already used the workplace social capital scale of copsoq iii to collect data or are planning to use the scale can apply the results of this study as follows first calculate the raw mean score of the six items coded 0255075100 next use table 6 to convert these scores into the corresponding metric scores an intervallevel scale is equidistant meaning that the increase of eg 5 points on a scale implies the same magnitude of increase in workplace social capital on the entire range of the scale as seen in fig 3 where mean scores are plotted against metric score this assumption does not hold for the ordinallevel scale clearly the curve is not a straight line the increase of eg one unit on a mean scale is much larger at the top than in the middle of the scale using the conversion table allows for increased precision of the workplace social capital scale discussion we found that the psychometric properties of the suggested scale for workplace social capital were satisfactory after having accommodated for local dependency each individual item worked as intended the scale was unidimensional and functions invariantly for women and men and for younger and older employees the scale for workplace social capital is valid for use at group level understood as valid for distinguishing groups not individuals the psychometric properties of the workplace social capital scale from copsoq iii were good having accommodated for local dependency through the use of testlets and all items worked properly the ordering of the response categories worked properly for all six items meaning that the expected increasing level of the latent construct across the response categories for each item are reflected in the observed data the results suggest that the scale fulfills the criteria required by the rasch model in order to quantify a latent variable the total score reflects the scoring structure indicated by developers of the scale in other words the rasch model provides evidence that the items form a reasonably unidimensional and essentially valid scale an essential feature of measurement implies equal intervals across the entire continuum of the construct being measured the initial analysis showed some problems with local dependency based on the pca of residuals the three tm items clustered in one group while the two ju items and te3 clustered in another group although this is not optimal from a measurement point of view the results are not surprising from a theoretical point of view since these items constitute different subdimensions of social capital while the three tm items are intended to measure the perception of trust in the relationship between management and employees the te3 and ju1 ju4 items address mutual trust among employees and justice as grouplevel characteristics as reflected in quotations from qualitative interviews 24 this might be especially true in the context of human services where employees typically have high discretion in tasks related to clients or patients including handling of conflicts and distribution of tasks 66 the measurement problem was solved by combining the items into two testlets which is a recommended procedure for this kind of issue 62 equal spacing between the scale categories is an underlying assumption for the mean scores to be meaningful we have shown that the mean scores of workplace social capital scale are not linear and do not have equal intervals along the whole continuum an increase of one unit on a mean score scale does not imply the same amount or magnitude of workplace social capital across the entire continuum the problem might not be that serious in the middle of the scale but is more pronounced towards the ends of the scale this is not in any way unique for the workplace social capital scale but is true for many ordinal scales although it is tempting and very common to use the numerical coding of ordinal variables as real numbers in statistical analysis the numerals assigned to the response categories are arbitrary and can be changed as long as their ordering is preserved 6768 a discussion about how to treat ordinal data in statistical analysis has been going on for a long time 69 and classical test theory and modern test theory offer different solutions however that discussion is beyond the scope of this article the ordinal mean score has been transformed to an interval scale latent estimate we recommend the use of the proposed metric score instead of the mean score the logit score is transformed to the 0100 interval which is a familiar range for copsoq users and where higher scores indicate higher workplace social capital a task for future studies will be to determine cutoff scores indicating high and low values of workplace social capital as well as relevant reference values for workplaces the results of this study showed that the scale is valid on a group level but not for individual use eg to follow an individual over time this is also in line with the theoretical basis of workplace social capital which deals with relationships at work in a review of the literature and guidance on measurement of social capital in general lochner kawachi and kennedy point out that an almost universal agreement is that community characteristics such as social capital ought to be distinguished from individual characteristics and measured at the community level 71 measurement at the workplace level can be done in different ways for example by observational studies document analyses or by questionnaire studies in accordance with the recommendation from lochner and colleagues 71 the copsoq measurement of workplace social capital can be seen as an ecologic characteristic of the group to which individual responses are aggregated rather than an attribute of the individual 24 as part of the present work we realized that workplace social capital has been defined and operationalized by the use of copsoq items and in numerous ways across different research projects however in the vast majority of the studies presented in table 1 we find only very sparse information on validity and reliability often only cronbachs alpha values or a reference to the fact that copsoq in general or specific scales are well validated a basis for all research is the use of reliable and valid instruments and it is therefore our hope that this article can be a step towards the establishment of consensus regarding measurement of copsoq iii workplace social capital future studies will contribute to further validation of the instrument a main advantage of our study is that rasch analysis has been used which belongs to the item response theory and does not require any assumptions about the distribution of the construct being measured the rasch model operationalizes the axioms of additive conjoint measurements which are the requirements for the fundamental measurement construction 49 50 51 52 the adequacy of the fit was evaluated by means of residuals ie the observed item responses were compared to the expected ones this is an appropriate method given the ordinal character of questionnaire data given that the data fit the rasch model a valid measurement is obtained and the sufficient statistic for the workplace social capital items is obtained on a logit scale and transformed into the 0100 range for reasons of convenience some limitations should be mentioned the proposed logit scores are valid only for similar populations of human service workers or similar occupations having daily contact with patients clients etc the workplace social capital scale fit the model after the items were combined into two testlets this implies that the proposed metric values are valid provided that there are no missing values on any of the items further research is needed to address construct validity in relation to other important constructs and for a better understanding of the construct when used in different contexts according to modern test theory validation is an ongoing process and modified versions of the questionnaire at hand or applied in new settings call for new evaluations 72 in the present study we have used a convenience sample of human service workers our findings showed that the scale worked satisfactorily and showed an ability to distinguish between groups even in a hightrust context such as human services while human service work shares many characteristics across countries the core of the work differs substantially from say industrial work 66 therefore we suggest replication of the study in a broader international sample to assess higher generalizability conclusions in conclusion we have established a scale based on the domain for workplace social capital in copsoq iii for use at group level in human service organizations the scale holds good construct validity as it satisfies the measurement criteria defined by the rasch model all relevant data are within the manuscript and its supporting information files data curation hanne berthelsen formal analysis emina hadzibajramovic funding acquisition hanne berthelsen hugo westerlund investigation hanne berthelsen hugo westerlund methodology hanne berthelsen hugo westerlund jan hyld pejtersen emina hadzibajramovic project administration hanne berthelsen visualization emina hadzibajramovic writing original draft hanne berthelsen emina hadzibajramovic writing review editing hugo westerlund jan hyld pejtersen

workplace social capital has been suggested as a useful concept when addressing organizational and social factors of the work environment the overall aim of the present study is to establish and evaluate the construct validity of a measure of workplace social capital based on the operationalization suggested in the third version of the copenhagen psychosocial questionnairethe present study is based on data collected as part of a validation and development project for the use of the swedish version of copsoq at workplaces and includes responses from 1316 human service workers answering a workplace survey six items from scales for organizational justice vertical trust and horizontal trust in copsoq iii were included in the analyses rasch analysis was used for scale validationthe analyses showed that the psychometric properties of the suggested copsoq scale for workplace social capital were satisfactory after accommodation for local dependency each individual item worked as intended the scale was unidimensional and functioned invariantly for women and men and for younger and older employees the scale was furthermore found to be valid for use for distinguishing groups not individualswe have established that the scale for workplace social capital measured by copsoq iii is valid for distinguishing groups eg work teams the scale exhibits good construct validity as it satisfies the measurement criteria defined by the rasch model

introduction in 2020 around 38 million people were estimated to be living with hiv globally 16 of whom remain unaware of their hivpositive status 1 since 2010 latin america has shown an increasing trend in new hiv infections among adults in 2019 there were an estimated 100000 new hiv infections and 21 million people living with hiv in latin america 1 hiv incidence is very high among men who have sex with men in the region accounting for 46 of the total new hiv infections in 2020 1 2 3 msm have an hiv prevalence at least 10fold higher than the general populations in brazil mexico and peru 4 5 6 therefore this group requires specialized and focused policies especially msm with social conditions conferring higher vulnerability 7 there is consensus about the importance of applying new strategies to make hiv testing services more convenient and attractive for those in need the aim is to reach the united nations target of 95 of people living with hiv being aware of their hiv status by 2030 however latin america is far from reaching this target wideranging estimates show that around 79 of men living with hiv know their status 1 in this situation the hiv selftest could increase hiv diagnosis paving the way to the first 959595 unaids target 8 a systematic review of seven rcts involving msm found that hivst increased hiv testing uptake by 15 times 9 in 2016 the world health organization recommended that hivst be offered as an additional approach to traditional hiv testing services while in 2019 the who recommended social networkbased hiv testing approach for key populations as part of the services package 810 in latinamerica the evidence of hiv selftesting across countries is limited studies in brazil 11 12 13 14 15 mexico 16 argentina 17 and peru 1118 have shown that almost all people surveyed in each study reported they would like to use hivst factors associated with decreased willingness to use hivst include the high cost of the test 18 being in a relationship and condomless anal sex in the last three months 16 concern about receiving results alone 12 and social stigma 71119 however these studies were applied in particular country settings such as urban or rural areas or as part of a project that included training to use hivst and most of them were conducted prior to the who recommendation of hivst in 2016 8 as part of the formative research for the imprep project in brazil mexico and peru this study aimed to assess awareness willingness and barriers to use hivst among msm from these countries using a uniform webbased survey methods study design we conducted a crosssectional webbased survey targeting msm living in brazil mexico and peru between marchjune 2018 details of the study design are described elsewhere along with the original analysis results on willingness to use prep 14 eligibility criteria were consenting �18yearold cisgender men residents of their respective countries and selfreport hivnegative status the questionnaire was programmed on alchemer 1 and surveymonkey 1 we advertised the survey on two geosocial networking apps and facebook 1 hornet users received two inbox messages linked to the survey and grindr displayed one popup advertisement per week to all users for two months on facebook 1 advertisements were targeted at gay and bisexual men to lessen potential discomfort with sensitive questions eg those related to sexual behavior answers options included i do not want to answer or i do not know these responses were considered missing for data analysis participation was voluntary and no incentives for participation were provided variables outcome willingness to use hivst was defined as the highest interest using a fivepoint likert scale in response to the statement i would use the hiv selftest even if i had to pay for it following prior studies accessing willingness to use hiv prevention technologies in latin america 13 20 21 22 sociodemographics we gathered information about age and selfreported raceskin color for brazil and peru this was classified as white and nonwhite while in mexico response options were indigenous and nonindigenous socioeconomic data were measured through monthly income and education we used the minimum wage for each country as a measurement scale in brazil we inquired about family monthly income for peru and mexico the question inquired about personal monthly income in peru it was categorized as low middle and high for mexico this was classified as low 3 middle 34 high �5 details of income stratification and rationale are described elsewhere 23 education level was dichotomized into less than high school versus high school graduate or higher education recruitment was dichotomized in gsn apps vs facebook sexual behavior participants were asked about sexual attraction and having a steady partner in addition we measured the frequency of using apps for sex and categorized as never sometimes and daily hiv perceived risk was measured with the question in your opinion what is your risk of getting hiv in the next year and dichotomized into low and high following previous studies 2024 the risk of hiv infection was assessed using the hiv incidence risk for msm scale 2526 used in previous analyses among msm in latin america 132227 the hirimsm was calculated based on sexual behavior over the last six months if the participant scored �10 points on this scale they were considered high risk otherwise they were deemed low risk participants were also asked about sex under the influence of alcohol or drugs and if they had sex in exchange for money or gifts each during the previous six months hiv testing awareness of biomedical hiv prevention sti testing participants were asked about previously testing for hiv with possible answers never last three months last 6 months last 12 months more than 12 months and never for those who answered never we inquired about reasons for not testing including options such as fear of a positive result selfperception of not being at risk for hiv infection shame of doing the test and reasons related to reluctance to go to the clinic we measured the use of hiv preand postexposure prophylaxis first prep awareness was assessed by asking if they previously heard of prep then a brief description of prep was provided before questions about prep willingness assessed using a fivepoint likert scale of willingness to take daily prep thus prep willingness was defined as anyone answering highly likely furthermore we asked about previous sexually transmitted infections diagnoses gonorrhea chlamydia and syphilisin the last six months 1314 awareness of and barriers to hivst to assess hivst awareness participants were asked if they ever heard about hivst for hiv diagnosis or not independent of their awareness the questionnaire showed a paragraph explaining hivst the need for a confirmatory laboratory test in case of an hivst positive result and information about the immunological window period for hivst after this explanation the survey inquired about their willingness to use hiv selftesting barriers to hivst were assessed with a fivepoint likert scale the statements were related to fear shame concerns and trust in using an hivst the questionnaire also inquired about the best way to provide counseling after testing and personal support to the user who receives an hivst the response options were a tollfree telephone call online chat mobile app or clinic visit we also asked what personal information they would be willing to provide if there was a website where they could register to order an hivst statistical analysis bivariate and multivariable modeling was performed using generalized linear modeling with poisson regression and robust adjustment poisson regression with robust adjustment was used to obtain efficient results closest to the mantelhansel prevalence ratio 28 results are presented as prevalence ratios adjusted prevalence ratios and 95 confidence intervals bivariate analysis was performed to evaluate the association between willingness to use hivst and sociodemographic sexual behavior hivsti testingprevention and barriers to hivst for each country the final multivariable model for each country included variables defined a priori as confounders irrespective of their statistical significance such as age education level monthly income and race then additional variables were assessed for inclusion in models for each country using backward stepwise selection variables with a bivariate pvalue 001 were included in the initial model and then eliminated if their multivariate pvalue was 005 backward elimination started with the least significant variable and then rerunning the model to repeat the process the final models only kept variables that remained significant after the deletion process but included all a priori defined cofounders statistical analysis was performed using r version 420 ethical issues the ethics committee approved this study in each country in brazil it was obtained from the irb of ini evandro chagasfiocruz in mexico the research ethics committee of the national institute of psychiatry ramo ´n de la fuente muñiz in peru the research ethics committee of universidad peruana cayetano heredia all participants provided their online informed consent before answering the survey which was completed anonymously results study population a total of 43687 respondents provided informed consent around 80 were eligible to participate and 433 completed the survey and were included in the study as shown in table 1 of the total eligible 588 34 raceskin color was differently distributed in each country reflecting its populations characteristics in brazil 472 were nonwhite while in peru 805 were nonwhite only 104 of mexicans selfreported as indigenous of the total participants 679 had a high school or higher education and nearly half of individuals were classified as middle income in mexico and brazil the majority were recruited from advertisements in gsn apps and in peru from facebook most participants 893 reported sexual attraction for men only and 264 had a steady partner the frequency of daily use of apps for sex was higher in brazil while in mexico and peru lower sex under the influence of alcohol was proportionally similar among the three countries but the chemsex was lower in peru compared to brazil and mexico transactional sex was somewhat higher in peru compared to brazil and mexico during the previous six months the selfreported prevalence of sti diagnosis was 133 in brazil 96 in peru and 66 in mexico in brazil high hiv risk perception reached 299 whereas in mexico and peru was similar however according to the hirimsm all participants had similar scores overall 525 reached the cutoff score for high hiv risk overall 198 never tested for hiv with the highest proportion in peru while brazil had the highest proportion of participants who reported an hiv test within the past three months the main reasons for not getting an hiv test were i feel afraid of a positive result i am not at risk of getting infected i feel ashamed to get tested the proportion of msm aware of hivst was 350 and the lowest proportion was in peru followed by mexico and brazil willingness to use hivst showed similar proportions and order brazil 437 mexico 363 peru 321 participants preferred posthivst counseling via tollfree calls by support or by clinic visits the personal data that participants would provide to get an hivst via website showed different concerns about privacy information brazil had the highest percentage of participants willing to give their names while in mexico was 618 and in peru 471 furthermore mexico had the lowest proportion of participants who would give their national identification number whereas in brazil this result reached 503 and peru 380 on the other hand similar proportions of participants from the three countries agreed on providing a cell phone number similarly a small percentage said that they would not provide any information barriers related to use hivst according to each country are depicted in fig 3 the most reported barrier was the posthivst counselling from a health professional additionally most of the participants strongly agreed or agreed with the need for pre and posthivst counselling another critical barrier was the difficulty of dealing with an hivst positive result according to 801 of participants who strongly agreed or agreed in contrast less than half strongly agreed or agreed on the statement i would know how to deal with a positive result if i used hivst other reported barriers that participants strongly agreed or agreed were the shame if someone saw they use hivst and the fear of using hivst alone lastly 382 strongly agreed or agree regarding the statement related to trust in hivst i would not trust an hivst in comparison to hiv testing from the clinic or health center factors associated with willingness to use hivst in the adjusted multivariate models reporting high monthly income and high educational level were associated with willingness to use hivst for the three countries and recruitment through gsn apps only for brazil regarding sexual behavior in plos global public health brazil high score in hirimsm scale the use of apps for sex in peru and sex under the influence of alcohol in mexico were associated with willingness to use hivst likewise willingness to use prep showed a positive association with willingness to use hivst in all three countries in contrast transactional sex in brazil and hivst awareness in mexico were inversely associated with willingness to use hivst barriers to hivst were also associated with willingness to use hivst in the final multivariate models among the three countries knowing how to deal with an hiv positive result was associated with willingness to use hivst while not trusting in hivst in comparison to hiv testing from clinic or health center was associated with lower willingness to use hivst in brazil and mexico being afraid to use hivst alone was associated with lower willingness to use hivst in mexico feeling ashamed if someone knew you were using hivst showed a similar effect lastly thinking that posttest counseling with a health professional is essential was associated with higher willingness to use hivst in all countries in contrast indicating an importance of pretest counseling was associated with lower willingness to use hivst only in brazil discussion this study provides information on awareness willingness to use and barriers related to hivst among a large sample of msm from brazil mexico and peru our results suggest that approximately 35 of participants in peru and mexico and 40 in brazil were aware and willing to use hivst across the countries willingness to use hivst was associated with higher income higher education and willingness to use prep existing preand postest counseling with a health professional and difficulties of dealing with an hivst positive result were the main endorsed hivst barriers in the three countries our regression models suggest some factors associated with willingness to use hivst that are common in brazil mexico and peru and other factors that are only significant for one or two countries socioeconomic indicators such as higher income and education level 11 29 30 31 32 were directly related to willingness to use hivst statistically significant for all three countries these relationships could reflect that more years of education could lead to a higher knowledge of new selfdiagnostic methods 3334 likewise purchasing power would be a precondition related to willingness to get an hiv selftest kit 3536 in countries where hivst is not available free of charge through the public health system as in brazil although we did not evaluate it here other studies have shown that the hivst kits price plays a critical role in its use 18 also our findings suggest that sexual health education approach including hivst might be crucial among key populations 37 38 39 since poverty lack of schooling along with existing social inequities are barriers to hiv services that could have been increased during and after the covid19 pandemic 1 willingness to use prep was directly associated with willingness to use hivst and it was statistically significant in the final model for all three countries this positive relationship could be explained since prep and hivst have a common target population and interest in both may represent individuals open to innovation in hiv prevention this finding suggests that hivst and prep could be offered together and delivered through the same platform previous studies have made both services available through a mobile app 4041 while other pilot studies have jointly offered prep and hivst 4243 with an increasing in testing telemedicine procedures and hivst distribution were implemented in brazilian prep services since the onset of the covid19 pandemic 44 and the acceptability of both strategies was very high 45 future research in latin america could explore the interaction of prep and hivst to improve prep adherence and testing frequency likewise a better understanding of the demand for these services the relationship of sexual behavior characteristics with willingness to use hivst differed by country msm at higher risk for hiv and sex under the influence of alcohol was associated with higher willingness to use hivst in mexico and brazil respectively both results are promising and indicate that msm with a high vulnerability for hiv may be more interested in hivst conversely individuals reporting transactional sex who maybe have higher vulnerability to hiv had reduced willingness to use hivst in brazil in our study the proportion of brazilian msm who strongly agreed or agreed with the statement i would be afraid to use hivst alone was higher among those reporting transactional sex vs not reporting which could partially explain our findings daily use of apps for sex was only associated with willingness to use hivst in peru thus in peru these apps could be segmented to a population group more adapted to the use of new technologies such as hivst however the use of apps for sex is lower in peru than in the remaining countries 187 of peruvians had never used an app for sex whereas in brazil and mexico that answer was only 7 likewise in peru participants were principally recruited from facebook 557 while in brazil and mexico almost 90 were reached through gsn apps the latter result could make it more difficult to find differences in the adjusted model for willingness to use hivst among those who use and do not use these apps in brazil and mexico surprisingly hivst awareness was associated with lower willingness to use hivst in the adjusted model for mexico this could be a sign that a communication campaign to clarify doubts and fears about hivst would be crucial especially highlighting the utility of hivst and its use as a preliminary test that would then require confirmation but can help identify individuals in need of further testing the lack of adequate information is a barrier identified and translated into two questions first only 279 of mexican msm from our sample had heard of hivst before second participants who disagreed with the statement i would not trust in hivst compared to hiv testing from the clinic or health center had significantly higher willingness to use hivst willingness in all three countries both results suggest an excellent opportunity for information campaigns distribution of hivst through web channels pharmacies and for hiv partner notification services indicating the need for posttest counseling had a positive relationship with willingness to use hivst in all three countries but the statement about the need for pretest counseling had an inverse relationship only in brazil the positive association with posttest counseling reveals that there would be tension between preferences for privacy and support 35 it would be interesting to know if virtual counseling would be an acceptable replacement 4647 a realtime conversation with a professional while knowing that the health professional is not observing the participants could be a relief for some participants it is a possible mechanism since 728 of participants agreed to provide their cell phone number to access an hivst through a website that requires this type of information conversely pretest counseling may be perceived by brazilian msm as an obstacle to obtaining the hivst kit or it may be seen as an intrusion to privacy if precounseling implies knowing the identity of the person who will use the test regarding barriers statements related to knowledge about dealing with an hivst positive result was associated with higher willingness to use hivst in all three countries in contrast fear of using hivst alone was associated with lower willingness in brazil and peru but not in mexico both results confirm the importance of counseling usually accompanying homebased testing studies 48 different nonpersonal counseling mechanisms have been piloted in urban and rural settings and highincome and lowincome countries 4950 virtual counseling represents an excellent opportunity to become a valuable tool to empower people for selfcare reducing the problems associated with hivaidsrelated stigmas 71119 approximately 20 had never taken an hiv test in our whole sample and another 20 had not been tested in the last 12 months which is worrisome considering unaids 959595 targets to end hiv epidemic 1 the possibility of implementing virtual or telephone counseling would increase the use of hivst 1051 and consequently increase hiv testing and diagnoses it could be helpful since most previously focused msm services in brazil mexico and peru are centered in urban areas and cannot cover all the territory however hivst could be an approach to expanding health services related to hiv and other stis as well as increase hiv testing uptake frequency and yield without social harms as previously observed in other settings 952 previous pilot studies conducted in brazil 53 china 54 uganda 55 nigeria 56 and south africa 57 have shown that hivst is highly acceptable and feasible to implement among msm and other populations among limitations first the crosssectional design did not permit causal inference we only assessed factors associated with willingness to use hivst second since it is a webbased survey the sample was not probabilistic and it is only representative of an msm population with access to smartphones or computers third the high attrition may preclude the generalizability of our findings as the characteristics of msm who do not complete the survey may differ from those who complete it as seen in previous studies 1358 in this study the msm sample who did not complete the survey vs those who completed was mainly composed by brazilians aged 1824 years nonwhite lower income and lower education forth selfreporting in a webbased survey could introduce a social desirability bias finally the questionnaires length was designed to be answered online which limited the number of questions conversely the studys strength lies in the analysis of three latin american countries with a questionnaire adapted for each setting this study would be the first joint research among countries in the region to assess willingness to use hivst the msm population was adequately targeted via facebook or apps such as grindr and hornet resulting in a worthwhile sample furthermore the privacy of participants to answer the questionnaire could be an advantage over facetoface surveys finally it is essential to mention the promising future of hivst as a consequence of covid19 especially in lowand middleincome countries the current crisis of public health services lays bare the need for innovative approaches to continue offering hiv testing services while maintaining a physical distance hivst could become a valuable tool to keep hiv testing advances achieved in the last years focused on the unaids target of 959595 to 2030 51 future research in this area needs to understand what factors and strategies could be crucial to delivering hivrelated health services successfully conclusions overall we identified factors associated with hivst that were relevant in all three countries sociodemographic variables such as income and education level other prevention variables such as the willingness to use prep and potential barriers that could be a challenge to hivst expansion such as the importance of preand posttest counseling for hivst and doubts about how to deal with a positive hivst result these findings should promote future research about hivst considering the cultural reception demand characteristics and other barriers or incentives that could play a crucial role among potential users all relevant data are within the paper and its supporting information files

hiv selftesting hivst is an essential tool within the combined hiv prevention package and has been available in latin america since 2015 however hivst use among key populations remains low this study describes awareness willingness and barriers to hivst among msm in brazil mexico and peru a crosssectional webbased survey was advertised in two geosocial networking apps grindr and hornet and facebook in 2018 we included cisgender men �18 years old who selfreported hivnegative status we used multivariable poisson regression models to calculate adjusted prevalence ratios apr to assess the factors associated with willingness to use hivst for each country a total of 18916 completed the survey 59 from brazil 30 from mexico and 11 from peru overall 20 of msm had never tested for hiv awareness and willingness to use hivst were higher in brazil than in peru and mexico p 001 across the countries the patterns of association of willingness with hivst barriers were similar most participants think posttest counseling is essential and that dealing with a positive result would be difficult apr 113 to 137 range of aprs across the three countries having the knowledge to deal with a positive hivst resulted in increased willingness to use hivst apr range 111 to 122 while a lack of trust in hivst compared to hiv testing in clinics was inversely associated apr range 080 to 090 in general willingness to use hivst was associated with higher income apr range 149 to 197 higher education apr range 113 to 142 and willingness to use prep apr range 119 to 172 efforts to increase hivst knowledge and resolve perceived barriers are warranted especially among msm with lower income and education from brazil mexico and peru personalized virtual counseling could be crucial among this population in addition those willing to use hivst are also willing to use prep it indicates that hivst delivery could be incorporated into prep programs within the brazilian public health system and eventually in mexico and peru

introduction child maltreatment is a major public health problem 1 it is estimated that one in eight us children will experience maltreatment by the time they reach adulthood 2 child maltreatment contributes not only to risk of immediate injury and death of children but also to cumulative and longterm risk to physical and mental health 3 4 5 the high prevalence of child maltreatment combined with its strong health risks suggests that effective populationlevel health education approaches may help to reduce this epidemic populationlevel health education approaches can have the greatest impact when they are focused on strong risk factors with high prevalence in a population 8 yet those risk factors that are most pervasive normative and accepted in a population can be the most difficult to address with such efforts due to strong cultural and ideological resistance current social norms in the usa regarding corporal punishment are an excellent example of such a risk factor despite the fact that social norms regarding physical discipline may be the most prevalent risk factor for child abuse in the usa 9 p 371 10 11 12 they also remain one of the most neglected and most intractable cp is defined as hitting or spanking a child with the intention of causing a child to experience pain but not injury for the purpose of correcting or controlling the childs behavior 13 cp is a strong risk factor for child physical abuse 14 one populationbased study found that parental use of cp increases odds of child physical abuse by nearly three times and by as much as nine times when an object was used 15 an increased use of cp is associated with an increased use of other forms of parenttochild physical and psychological aggression as well as acts of neglect 16 furthermore there is an increased risk of cps involvement among infants who are corporally punished 17 cp use also is strongly associated with presence of intimate partner violence in families 1218 which is a strong risk factor for child maltreatment and in some states considered a type of maltreatment itself hence children that experience cp are at increased risk for experiencing other acts of violence aggression and neglect by their parents beyond risk for experiencing more violence cp also raises risk for additional poor health outcomes in children in analyses that controlled for more severe acts of child maltreatment children that received cp were at increased risk for mental and physical health problems 1920 and as well as subsequent aggressive behavior 142122 children who are spanked also are more likely to approve of physical aggression as a means for solving conflicts with peers 23 moreover the mean level of punishment experienced in childhood has been linked with the risk for perpetration of intimate partner violence in adulthood 24 thus use of cp not only raises risk of substantial harm and reduced wellbeing for children it also perpetuates a cycle of violence given the weight of empirical evidence citing risks that cp use poses to children many professional organizations focused on childrens health such as the american academy of pediatrics have advocated against its use 2526 despite this 76 of men and 65 of women in the usa believe that cp is a necessary disciplinary tool although these approval rates do vary across racial and ethnic groups it is still a majority of blacks hispanics and whites that support cp use 10 importantly having a favorable attitude toward cp use is a strong and consistent predictor of its actual use 27 28 29 30 31 32 positive attitudes toward cp are especially common among parents who experienced cp during their childhood 23 33 34 35 indeed adults that experienced cp as a child are more likely to use it with their own children 36 as such these positive attitudes help explain not only the strong intergenerational transmission of cp but also the spillover effect of cp that leads children to approve of using aggression with peers 23 to break this cycle health education researchers and practitioners would be aided by better understanding potentially modifiable factors linked with attitudes supportive of cp use and similarly identifying points of resistance to changing such attitudes these topics have been addressed thus far in a limited body of research which has shown parental expectations of outcomes of cp to be strongly linked with attitudes toward cp similarly other research has linked frequent use of cp to parents expectations of immediate compliance appropriate behavior in the longterm and respect for parental authority 37 hence we know that parents beliefs about whether or not cp leads to positive or negative outcomes are important however it is likely that other types of beliefs influence these attitudes as well most prior research on this topic has been deductive and therefore limited by the scope of investigatorgenerated hypotheses in this study we took a more open inductive approach to try to generate new ideas and a better understanding of common points of resistance to educational messaging relevant to changing social norms regarding cp to do this we used a novel data source to examine user generated comments provided in response to media coverage of a study that showed cp was related to increased aggression among children which some might have viewed as educational regarding the potential harms of using cp the creation of web 20 and the resulting shift from static to dynamic usergenerated content has changed the way the average citizen is able to interact with the internet by providing an opportunity to express opinions on issues via mass media 38 platforms for usergenerated c a taylor et al content such as social media websites blogs chat rooms and free text comment platforms allow users to express thoughts and opinions in real time as part of daily life the resulting wealth of free easily accessible information presents a unique opportunity for data collection in stark contrast to the reliance on selfreport and questionably reliable memories that characterizes traditional research usergenerated content in the public domain allows researchers to observe actual behaviors and communications as they naturally unfold 39 without participant knowledge of observation for research the hawthorne effect in which individuals modify or improve their behavior as a response to being observed is virtually eliminated 39 additionally this method of data collection allows researchers to derive a naturally occurring sample from a vast global community greatly diminishing the risk of biased respondent selection 3940 multiple sources conclude that this new evolving data source is too rich inexpensive and easy to collect to be ignored 39 40 41 42 43 44 we anticipate that assessment of such data will be invaluable to translational researchers and health educators alike who are often challenged with overcoming barriers and natural resistance to research findings that go against conventional wisdom and norms while the opinion gap between scientists and the general public is often quite large 45 we hope that this assessment of responses to a news media report of new research findings may provide a unique and potentially rich source of data for better understanding that gap we used this unique sample to conduct an indepth inductive investigation to search for new themes regarding cp attitudes perhaps not before captured via more traditional data sources and to determine points of resistance useful to changing such attitudes method sample in 2010 the release of research findings that linked use of cp with children at 3 years of age to increased child aggression at 5 years of age generated multiple news stories in the popular media among these stories an article appearing in time magazine 46 provided a description of the study findings indicating that spanking was associated with subsequent increased child aggression even after controlling for a host of other issues such as maternal experience of depression alcohol and drug use intimate partner violence and whether or not she considered abortion while pregnant with the child the article also indicated that the american academy of pediatrics does not endorse spanking under any circumstances the time magazine story as covered by yahoo news prompted nearly 1000 online comments on the yahoo news site the current study examined a random sample of these comments 59 of the full sample use of the full sample was not necessary because once saturation had been reached further qualitative analysis of comments would have had little yield the demographic characteristics of our sample were unobtainable and hence unknown coding and textual analysis we conducted a textual analysis of the comments regarding attitudes toward cp in general and the research study specifically a codebook was developed and two rounds of coding were conducted that included a content analysis and use of a grounded theory approach to uncover ideological nuances grounded theory is employed for discovering theories concepts hypotheses and propositions directly from data 46 use of grounded theory was especially appropriate for this study because the research team did not enter the study with a priori hypotheses but rather used analysis to identify and describe themes in the responses to the news article furthermore our coding process started with small chunks of data which lent itself well to the open coded procedures used in grounded theory approaches the initial codebook and codes were developed by the principal investigator who met with the project manager and project assistant several times beliefs linked with approval of corporal punishment during the initial 2 weeks to discuss the codes and the codebook structure the first 5 pages of comments served as practice for the coding team and a review of codes and coding techniques initially three global codes were developed for the content analysis positive attitudes toward cp negative attitudes toward cp and general comments about the research at least one of these global codes was assigned to each comment and then emergent sub codes were assigned particularly sub codes that expanded upon the positive or negative attitudes toward cp as emerging themes were identified and codes were developed the project manager created a codebook that included definitions of codes and identified hierarchical relationships between codes for example comments that indicated cp was good for all children received the code goodall comments that indicated that cp was good but should be used as a last resort received the codes goodwhen and last resort this sub code was defined as when done as a last resort when other types of discipline have failed and was nested under the sub code goodwhen in the second stage of coding the team sought to explore belief systems embedded within the comments as in the first stage the coders first met as a team to discuss emergent ideological codes and then met with the pi to review these new codes constant comparison and memos were used to develop substantive codes and explore their theoretically coded relationship throughout this stage of coding for example the team developed the code kid power after identifying comments that alluded to the childparent power dynamic and the importance of cp in maintaining that balance each team member working independently to code approximately 50 comments and then the coding team convened to discuss the coding and reach consensus on the codes if the coding team could not reach consensus they reviewed the comment and the proposed codes with the pi and final consensus was reached the team discussed and added new codes and definitions to the codebook as needed throughout the coding process the code data were entered in atlasti software by both members of the coding team to detect and correct any errors with data entry a code check was conducted by comparing the codes entered by one team member to the codes entered by the other team member this code check was performed by printing out the coded comments and comparing the printouts for differences the double entry and code check procedures were designed to enhance the reliability of data entry results approval of cp a substantial majority of those commenting on the time magazine story 47 covered by yahoo news regarding the link between spanking and subsequent increased childhood aggression expressed approval for the use of cp with children among the group of respondents who expressed approval of cp most provided explanations for their positive attitudes comments could be assigned multiple codes hence explanations were not mutually exclusive when assessing the commenters attitudes in general toward the research study that prompted the news story 40 of the sample included comments specific to the study of those that commented about the research study specifically more than 90 disagreed or strongly disagreed with the study findings approval of cp and personal experience the most common explanations offered for approval of cp were based on personal experience most common of all was the persons own experience of having been spanked as a child and his or her selfassessment that i turned out okay the following comments exemplified this common sentiment i was spanked growing up so was the rest of my brothers and sister when we were bad and to no bad effects on us i am not an aggressive person and my mother spanked me on a regular basis c a taylor et al the second most common explanation of approval of cp was expressed as a belief that cp improves child behavior here are some comments exemplifying this theme a timely and well deserved spanking helps a child understand consequences for misbehaving spanking teaches kids consequences for their sinful actions and when they grow older they think things through more it is the centuries old method of child discipline the next most common comments expressed the conviction that other forms of discipline were not as effective as cp in correcting child behavior problems the following comments exemplify those in this category timeouts do nothingyou walk away and kids sit there plotting what they are going to do next until momdadteacher comes back spanking should not be done in anger but with the intent of delivering a consequence of punishment for wrong doing simply talking sternly to or time outs just dont do the trick many commenters also expressed the opinion that cp was simply a form of discipline but not abuse there is a difference between discipline punishment and abuse people need to learn how to know the difference there is a distinct difference between beating abusing a child and spanking them there is a big difference between physical abuse and disciplining your child with a spanking it has its place and it is effective even the police tell you it is not abuse to whip a child with belt as long as it is on the behind and of course not excessive there is nothing wrong with a good ole butt whipping from time to time finally the last two most common themes contained echoes of the basic idea that cp does no harm and may produce good results many commenters noted that they had spanked their own children and that those children had turned out okay comments from this group typically referenced the respondents use of cp and their wellbehaved children for example i believe in spankings i have 4 wonderful kids that have been spanked we get so many compliments on how well behaved our kids were other comments echoed the thought that spanking was very common in my generation and my generation is okay comments typical of this group emphasized the positive results of cp for an entire generation i am 67 and my generation got their butts whacked on a regular basis and it did no harm to our generation we are the last generation with any moral fiber left kids of the younger generations are a much larger problem on average than we were overall these findings can be summarized as expressing a firm belief that cp does no harm is an effective form of discipline produces positive beliefs linked with approval of corporal punishment results and that other forms of discipline do not work as effectively more than a third of comments expressing approval of cp also specified that such approval was dependent upon specific conditions the most frequently mentioned condition was in regard to the manner in which the parent implemented cp nearly one quarter of the approval comments expressed a belief that the parent should take certain steps before implementing cp such as being calm explaining to the child why cp is being used and ensuring cp is not excessive in addition many of the comments noted that cp should be used as one strategy along with other forms of discipline such as prior verbal warnings or taking away privileges other less frequently mentioned conditions for approval included using cp as an adjunct to positive reinforcement specifying which body parts were appropriate for cp and limiting use of cp to use in response to certain egregious behaviors ideologies linked with approval of cp among the 412 comments in our sample that indicated approval of cp analysis revealed that most of these comments also indicated macroideologies about our culture the most common of these comments expressed the conviction that todays generation or society is somehow lacking or worse off than prior generations because social changes have diminished discipline one comment summarized the thoughts of many in this group yeah people continue to get so much more sedate and controlled as we continue to soften discipline theres so much respect this day and age in our societies are you people who write this really that naive and stupid you cant see the correlation between the extreme violence and disrespect today and the lack of any real discipline i cant believe the disrespect and lazy behavior i see from this next generation common thread no discipline nearly as many comments focused on beliefs that tied a single factor to an undesirable outcome for example commenters stated that the african americans that got spankings for the most part stayed out of prison i can personally say thank you mom and dad for whooping me as a child because that kept me out of jail the ones that arent spanked and need it turn out to be on welfare and cant hold a job many commenters who approved of cp also noted their distaste for any sort of societal interference with parenting particularly from the government or scientists typical comments included the government and these researchers have taken even our rights as parents away and the government has stepped in again where it has no business the next most common theme identified poor parenting with a lack of control over childrens behavior some sample comments were some kids need a good whippingspanking and the parents dont give it to them guess who is in control of that household someone must be in control and if the parents choose not to be the children will automatically take charge without the parents setting the necessary boundaries and enforcing the rules their children will do as they please and thumb their collective noses at the supposed authority figure other emerging themes centered on children having too much power in the household some examples of this theme were kids now days have more rights than parents do most kids have no respect for their parents or eldersthey walk all over them and can get away with it there are children out there now who run the house because parents have this new thing called a time outoooohhh so scary disapproval of cp of the 112 commenters who expressed disapproval of the use of cp with children more than threequarters of this group specified conditions under which they considered cp inappropriate or harmful of these commenters more than half identified situations or conditions in which they especially disapproved of cp these situations included use of cp when the parent is angry when the parent is impaired in some way such as being highly stressed or under the influence of alcohol or other drugs or when a parent relies exclusively or too frequently on cp rather than using other forms of discipline in addition 28 of these comments provided reasons for disapproval of cp the most frequently mentioned reasons included the belief that nonphysical discipline is effective that use of cp leads to negative child outcomes such as fear withdrawal or antisocial behavior and that the respondent raised his or her children without using cp and the children turned out fine here are some examples of quotes from respondents that disapproved of cp spanking is for apes talking it through and explaining what was done wrong is what humans should do use your words not your actions and kids will do the same i was lucky enough to get parents that had the patience and had the brains to raise my brother and i the better way spanking a child what genius finally figured out that aggression teaches aggression hitting a child teaches them that hitting is a way to solve a problem there are many ways to discipline a child and teach proper behavior spanking or hitting them is not one of them i have never spanked my children i have a grandson that has never been spanked i dont live in a fairy tale land ive worked with children with special needs for 30 years many of which had emotional problems stemming from bad parenting imagine being 23 feet tall and your parent the person you trust to care for you and protect you starts hitting you who do you turn to there is no one beliefs linked with approval of corporal punishment discussion the findings of the current study complement and are in line with prior quantitative survey studies regarding the us populations attitudes toward cp first although we do not know the demographic makeup of our study population the prevalence of support for using cp found in our study was on par with the us general social survey data showing that 76 of men and 65 of women approve of cp 10 in addition the approval rates of cp reported in the current study are highly consistent with existing empirical data on parenting behaviors two large national studies have shown that between 65 and 70 of parents use cp to discipline their toddlers 111248 the consistency found between rates in this study and in large national studies on this topic suggest that the current study sample may be comparable at least on this topic to larger more representative us samples hence our methodology of sampling and coding a large number of comments in a relevant public online forum may suggest a novel approach to data sampling and analysis of public opinion the fact that online media accounts of an empirical study linking cp to child aggression prompted thousands of individuals to respond to the content and to the overall idea of the research suggests that many people hold strong feelings about the topic the openended nature of our content analysis provided a unique opportunity to use social media in order to better understand individuals resistance to information that cp can raise significant risk for harm in children the comments analyzed in this study provided insights into the conditions under which the public approves of cp as well as into the more macrolevel cultural beliefs and ideologies associated with such approval although our data might represent those with the strongest viewpoints individuals with staunch opinions on a topic are often the most difficult to approach with information contrary to their viewpoint therefore understanding these points of resistance as well as how common they are is an important step toward improving upon the existing evidencebased practice for the primary prevention of child physical abuse and reducing the prevalence of cp use the majority of respondents in this study rooted their support of cp in conditions related to instrumental reasoning including opinions such as cp is an effective disciplinary strategy cp produces no ill effects and cp is more effective than other forms of discipline to the latter point time outs in particular were much maligned yet it is likely that many parents do not apply the necessary steps for it to be effective 50 these findings echo those of prior research that sought to better understand support for cp by using other methodologies such as telephone surveys eg 35 however these commonly held notions are inconsistent with the empirical evidence on the risks of cp dozens of studies have shown that cp is not likely to promote childrens longterm prosocial behavior and increases childrens risk for physical behavioral and mental health problems such as obesity aggression and anxiety respectively 14 19 20 21 22 hence this is an area that needs better translation to the public also common were comments expressing the belief that cp is acceptable under certain conditions known by some as the conditional cp argument 5152 this argument does not promote cp but reasons against a wholesale ban on cp noting the effects of cp are not necessarily negative or positive but may be either or both depending on many other conditions 52 conditional arguments suggest that cp should be concomitant with other disciplinary methods should be delivered when parents are calm and not out of control such as when using substances should not be excessive and should be delivered within the context of an otherwise loving and warm parental relationship however qualitative analysis of parentchild interactions suggests that most parents who use cp probably do not follow these guidelines 53 furthermore little empirical evidence is available to support conditional arguments for example three recent empirical studies using large national samples of young children showed that cp is harmful to children even when such punishment is used c a taylor et al in the context of a maternalchild relationship that is otherwise high in warmth 215455 a powerful potential lever for shifting attitudes about cp by addressing instrumental and conditional arguments is a public health campaign designed to educate the general public about the risks and harm to children linked with cp instrumental arguments might best be countered by the empirical evidence showing that the likely risks of using cp outweigh the possible benefits and that other methods of child discipline can be just as or more effective than cp without concomitant risks of harm to the child indeed lack of knowledge regarding the consequences of hitting has been an important risk factor targeted in universal campaigns designed to prevent child physical abuse and showing some promising results 56 messages of the harms of cp and effective alternative forms of discipline might be integrated if theyre not already into existing campaigns as well as developed into new locally appropriate ones the ideological themes seem to broadly represent an overall narrative that children must be controlled that good discipline is control via hitting and that parents not only have the right to exert such control but they must in order to be considered good parents there is resentment of external forces that suggest parents should not exert such control over their children there is the belief that to not use cp is to promote children being out of control and ripe for contributing to crime incivility and general social ills this viewpoint again runs in contrast to empirical data eg 14 and yet the theme holds strong we think these beliefs can be countered with education about the effectiveness of a variety of nonphysical disciplinary methods eg 57 as well as messages regarding the need to balance parental rights with childrens rights and wellbeing childrens rights are rarely talked about at the national level in the usa but at the global level the un convention on the rights of the child has been ratified by all countries but the usa 58 furthermore many feel that religious and biblical doctrine most notably the oft quoted spare the rod spoil the child supports and justifies parental rights to use cp indeed parents who report that they are most likely to seek professional advice regarding child discipline from a religious leader have four times the odds of using cp as those who seek such advice from pediatricians 59 one way to address such ideologies might be to engage trusted andor prominent community leaders such as religious leaders pediatricians and politicians to speak out publicly against the use of cp disapproval of cp by respected community leaders might help to shift norms regarding the acceptability of cp 35 for example following president obamas public statement supporting the rights of gays to marry polling data indicated a shift in the black community toward greater acceptance of samesex marriage 60 study limitations our unique sample source provided data from individuals regarding their beliefs and opinions on a controversial social topic however usergenerated content as a data source is not without limitations first our sample is a convenience sample of individuals who provided unsolicited comments in an online forum we were not able to identify respondents demographic characteristics geographical region or related factors as a result the sample may be biased in ways that we cannot address with available data this limits the generalizability of study findings user dialog in online forums particularly with regard to controversial topics is frequently characterized by comments written in very emotional language 38 these comments are frequently urgent impulsive and reactive 38 therefore it can be deduced that users inclined to provide unsolicited comments in such forums are likely to hold strong opinions on the topic which especially when paired with the incivility that frequently appears in online comment threads 61 might skew the comments to extreme viewpoints in addition our sampling methodology precluded us from gathering any systematic data regarding key respondent demographic characteristics however the anonymity afforded in such forums also means that the likelihood of social desirability bias is beliefs linked with approval of corporal punishment greatly reduced furthermore there is reason to believe that individuals providing anonymous online comments may be more socioeconomically and raciallyethnically diverse than other study populations mobile technology usage is helping to bridge the digital divide of economic and social inequality in access to technologybased information 6061 for example blacks and hispanics have higher smartphone ownership rates than do whites 62 and young people have especially high rates of mobile technology use even among lowincome individuals 63 implications for practice and future research use of cp substantially increases childrens risk for being physically abused as well as experiencing other harms to their wellbeing if we are to change social norms about the use of cp we must better understand the disconnect between the empirical evidence demonstrating the harms of cp and the highly prevalent attitudes and ideologies that support its use indeed american support for cp especially for children ages 5 and younger has continued at high rates despite research that has shown cp tends to exacerbate and perpetuate negative child outcomes such as increased levels of child aggression one of the very behaviors parents are often trying to eliminate when they use cp with a better understanding of the roots of prevailing norms regarding cp we can develop improved public health prevention and health education strategies designed to counter false beliefs and provide alternative discipline approaches our study identified several specific points of resistance that such strategies will need to overcome first support for cp is often couched in instrumental beliefs based on the conviction that cp is an effective means of promoting positive behavior and minimizing negative behavior in children it will likely take credible community leaders and professionals delivering the message 59 either based on research evidence community values or both to dispel these beliefs there also is a clear role for a public health approach to promoting positive parenting and discipline strategies such as those provided by triple p 6 a program shown to reduce rates of child maltreatment 7 our research suggests that it is imperative to include content on the harms of cp into more widely available forms of parent education such as the center for disease controls essentials for parenting toddler and preschoolers an accessible website that provides important education to parents and professional about topics related to discipline but currently does not explicitly advise parents not to use cp 62 in fact the cdc has just released a document that suggests the need to promote positive parenting through both public education campaigns and legislative approaches to reduce use of cp as key strategies for preventing child abuse 63 in order to advance child physical abuse prevention education efforts more research is needed into how to most effectively and costeffectively change the beliefs that support cp use and provide parents with alternative nonviolent tools for discipline second the value of parental rights and control currently trumps that of childrens rights and wellbeing efforts are needed to tap into parents sense of wanting to do right by their child and raise a child that is civil wellbehaved and healthy and to link those desires with positive parenting and disciplinary behaviors other than cp the un convention on the rights of child ratified by all countries except the usa has provided an important framework for many countries aiming to shift social norms regarding cp 64 and prevent child physical maltreatment 65 spurred by this convention 49 nation states have now adopted universal bans on cp 66 without the crc framework to fall back on in the usa research is needed particularly to understand how best to help parents value childrens rights as well as their own and see them as being paramount to child wellbeing and safety third those parents whose beliefs about cp are couched in political or religious ideological beliefs might be most amenable to an appeal from a respected political religious or other community leader at present seeking advice about discipline c a taylor et al from religious leaders raises risk for cp use 59 hence there is a great need to work with leaders of faith to educate them about the harms of cp for children and roadmaps for such practice are available 67 for all of these resistance points we suggest that it may be most effective to frame positive parenting and discipline education as helping parents to make an informed choice in promoting their childrens wellbeing and improving their childrens likelihood of success in life strategies perceived as soft on discipline interfering with parental rights or delivered by noncredible sources will likely be met with strong opposition while much research has been done in health message framing in general 6869 to the authors knowledge no research has been done on framing health messages around positive nonviolent parenting this is an area ripe for child physical abuse prevention research the rise of interactive media has created a platform for average citizens to express their opinions and beliefs and in doing so also has created a platform for researchers and educators to observe and moderate online discourse in real time though our findings are congruent with several studies 3861 which found online discourse to be primarily driven by emotional polarized comments we recognize its potential as a tool for both understanding the root of pervading social norms regarding cp of children in the usa and delivering education about positive parenting strategies brossoie et al 41 found that when knowledgeable posters participated in the discussion they were able to regulate both the depth and quality of discussion as well as provoke diverse thinking and more thoughtful posts from other participants in this vein as interactive media continues to evolve it is worthwhile to explore the use of educated moderators in these settings as a method of guiding online discussions regarding cp and other important healthrelated topics conflict of interest statement none declared

this study employs a novel strategy for identifying points of resistance to education efforts aimed at reducing rates of child physical abuse and use of corporal punishment cp we analyzed online comments n ¼ 581 generated in response to media coverage of a study linking cp with increased child aggression most comments 71 reflected approval of hitting children for disciplinary purposes reasons for this approval were rooted in beliefs linking the use of cp with positive or neutral outcomes such as i was spanked and i am okay spanking improves child behavior spanking is more effective than other forms of discipline and spanking is not abuse however also linked with approval were more macroideological beliefs about society such as todays generation is worse off than previous ones outside interference with parenting is wrong one cause leads to an outcome justifications for hitting children rooted in religious doctrine bad parents cannot control their children and children have too much power our results suggest a need to better translate and disseminate empirical findings regarding the negative effects of cp to the public in a way that is highly sensitive to parents needs to feel in control and effective when parenting

introduction the sarscov2 pandemic has highlighted the importance of infection prevention at individual and community levels the world health organization has indicated that for public health infection prevention measures to be successful all members of society should be fully engaged 1 these measures include but are not limited to physical distancing masking hand hygiene avoiding poorly ventilated indoor spaces and isolationquarantine if infected or exposed for efficient buyin and contribution to these measures individuals should understand the risks mode of viral transmission and consequences of infection as such the success of infection prevention measures depends on individual and communitylevel awareness and the adoption of infection prevention behaviours which in turn depends on their perceptions and cognizance of risk while effective public engagement has been highlighted as key to gaining buyin for improved infection prevention practices 2 3 4 challenges related to socioeconomic and other factors remain and may compromise infection prevention measures this is especially so as the pandemic continues to evolve with unequal effects and impact on different economies and populations 56 a compromise in infection prevention behaviour by one individual could cause reverberating consequences which can increase infection risks not only for the individual but also for other people addressing infection prevention effectively requires due consideration of the prevailing context and associated insight into the factors that influence and by extension can be used to motivate positive infection prevention behaviour as such additional research to explore public awareness perceptions and behaviours about sarscov2 and how these may influence adherence to public health measures is needed especially in lowand middleincome countries the conceptual framework used to develop the survey was adopted from the health belief model 7 according to the hbm behaviours are adopted or changed by individuals when they perceive that the consequences of previous behaviours may be severe andor they may benefit from the behaviour change it also highlights the importance of barriers as a powerful predictor of behaviour change utilising such a framework contributes to better design of targeted questions rather than development based on intuitive hunches or guesses 8 we drew on this model in the development of a survey tool to be utilised across india and south africa india and south africa 9 are countries with emerging economies where the sarscov2 pandemic has had a significant impact 10 over time and in their respective continents each of these countries had comparatively high burden of covid19 infections as well as related complications and deaths 10 redeploying the capacity within an existing research collaboration focused on infection prevention and control and antibiotic stewardship across participating sites in these two countries 1112 we investigated the publics perceptions and awareness of sarscov2related risks and infection prevention practices through analysis of data contributed by participants across the two countries methods study design we conducted a crosssectional weband paperbased survey data were collected by convenience sampling using a selfadministered questionnaire any adult member of the public who provided informed consent before participation was eligible to participate respondents were resident in either of the participating countries at the time of participating in the survey we had hypothesized that there would be no difference in the responses between participants in india and south africa study development a crosssectional survey through online and offline tools was conducted from over a 3month period report on the study was according to the strobe guidelines 13 the research teammade up of pharmacists physicians nurses social scientists patient advocate and public engagement specialist and quantitative data analystsdesigned a 42question survey to elicit information on the publics knowledge perceptions and awareness of sarscov2 infection risks the 4part survey included participant demographics general knowledge of sarscov2 perceived risks and barriers and selfefficacy in south africa survey questions and participant information leaflets were translated into isizulu isixhosa and afrikaans languages whereas in india the paperbased survey was translated into malayalam for local distribution the survey was piloted with members of the public and relevant revisions were made before dissemination study settings and participant recruitment the study was set in india and south africa during the peak of the covid19 pandemic across both countries the minimum sample size was calculated as 385 for each arm of the surveyindia and south africa this will provide an estimate of the proportion of respondents who have knowledge attitudes and perceptions of sarscov2 infection with 95 confidence and an alpha level of 005 to detect statistical significance assuming that the expected proportion of respondents to have knowledge of covid19 is 50 the survey was open for participation over a 3month duration any member of the public resident in any of the two participating countries was eligible to participate voluntary response sampling with some element of snowball sampling was utilized to reach as many participants as possible for online participation individuals were informed of the survey through invitations sent by members of the research team to their various professional and personal networks in addition the researchers contacted representatives of various sectors of the publicwho also helped to distribute the survey within their own networks the offlinepaper survey was conducted by researchers who distributed copies of the questionnaire among participants at the study site in kerala india patients and patient carers who visited any specialty in the hospital at that time were invited to participate in the survey all invited individuals in the participating countriesboth online and paper survey participantsreceived participant information leaflets and those willing to participate had to provide informed consent before commencing the survey participation was voluntary across both countries in south africa the survey was available online in three languagesisixhosa afrikaans and english in india the survey was available online in the english language and in the paper format in two languages english and malayalamthe prevalent local language at the study site in kerala where the paper forms were distributed during the survey development and dissemination period use of the paper form for the survey was not possible in south africa due to the covid19 restrictions at the time in india the paper forms were permissible for distribution following appropriate covid19 infection prevention measures therefore participants had a choice to participate either online or using the paper version of the survey data collection data from selfcompleted survey forms were collected by researchers from 15 september to 15 december 2020 and coincided with the first wave of the sarscov2 pandemic in india and the beginning of the second wave in south africa in both countries the online version of the survey was available via the platform qualtrics in india in addition to the online platform in english paper survey questionnaires were also distributed among participants at the study site in keralaa 1350bed tertiary academic hospital in an urban area 12 while the hospital has different units for patients with different conditions it was utilised mostly for covid19 cases during the pandemic patients and patient carers who visited any specialty in the hospital at that time were invited to participate in the survey all invitations were issued while informing participants that participation was voluntary and that they could decline participation with no risk of prejudice participant selection at the hospital was not randomised medical social workers who assist a lot in patient care at the study site went around the waiting areas of the hospital and invited participants to complete the survey this was done as time allowed throughout the data collection period between 270 and 290 copies of the paper forms were shared to respondents some of the respondents returned more than one formexplaining that people around them had indicated interest and they had made additional copycopies to share ethics statement the study was approved by the relevant human research ethics committees at the amrita institute of health sciences kerala india and the university of cape town south africa a patient advocate and public engagement specialistcivil society champion was involved in the design of the study material and also contributed as an author members of the public participated in the review of the survey tool and provided feedback for its modification formal consent was obtained prior to participation in the anonymous survey for the online and paper versions of the survey consent was indicated by the participant ticking the relevant box for consent on the survey form completion of the questionnaire after being provided with the participant information leaflet was also taken as an indication of informed consent to participate all individuals were informed of their right to refuse to participateand that there was no risk of prejudice attached to a refusal to participate statistical analyses data from participants who completed the paperbased format were captured in a microsoft excel file and codes assigned while data of participants who completed the online form were exported to ms excel the data from the paperbased and online versions of the survey were cleaned and combined descriptive statistics were used to report participant characteristics and survey responses the underlying outcomes were awareness of the pandemic perceived threats and barriers and selfefficacy responses were captured as categorical variables reported as percentages of received feedback for each item of interest or for certain questions data were scaled from strongly agree to strongly disagree pearsons chisquared test was used to assess relationships between variables and a logistic regression analysis was conducted with covid19 vaccination as the response variable p 005 was considered statistically significant for both tests for logistic regression analysis the variable was coded as 1 if people were willing to take the vaccine and 0 if otherwise both pearsons chisquared and regression tests were conducted using r 14 results participant demographics there was a total of 844 respondents s1 data there were 318 respondents to the online survey and 342 patients or patient carer respondents to the paper survey in india the response rate for the online survey was 876 calculated as the ratio of participants who clicked on the survey link versus those who commenced participation the response rate for the paper version of the survey could not be estimated as respondents returned a higher number of the completed survey forms than the initial number disseminated indicating the forms had been copied and shared more widely there were more female than male respondents three entries for age were excluded resulting in a total response of 657 for age entries most of the respondents in india and south africa were in the 2029year and 4049year age groups respectively majority of the participants across both countries had posthigh school education five participants selected other in response to the question what is your highest educational qualification and noted other educational qualifications as related to a diploma in elementary education secretarial diploma previous radiography teaching experience supplier relationship management supply chain management and one had no further information the percentage of student respondents was higher in india than south africa unemployment was higher among respondents in india than in south africa while there were more selfemployed and retired respondents in south africa knowledge and concerns of sarscov2 transmission and infection reported sources of sarscov2 information completed by 652 and 172 participants in india and south africa respectively are shown in fig 1a and1b across both countries traditional news channels and media and journal publications were the most common sources of pandemicrelated information among respondents along with social media government websites and family and friends among those who indicated use of social media for pandemicrelated information facebook and whatsapp were the most frequently used sites as shown in fig 1a and1b in table 2 the respondents knowledge of sarscov2 transmission routes infection course and preventionmanagement options is summarised the primary route of sarscov2 transmission identified was nasaloral droplets airborne particles and infected body fluids more than half of the respondents also demonstrated knowledge of sarscov2 incubation and symptom manifestation quarantine objectives and general duration of isolation for infected patients more frequent hand washing was reported across both countries however a higher percentage of respondents in south africa than in india noted no difference in their hand hygiene practices overall 750 of all the respondents indicated their willingness plos global public health to receive vaccination when it becomes available however the percentages were higher in india than in south africa the most common reasons cited for not accepting vaccination were perceptions of rushed vaccine development and the futility of vaccines for what respondents considered a selflimiting flulike illness selfefficacy perceptions of sarscov2 infection prevention measures respondents perceptions and concerns about their ability to cope with sarscov2 infection prevention measures are presented in fig 2 given their perceived knowledge and awareness of the pandemic and infection risks more than half of respondents in each country reported that they have sufficient knowledge of sarscov2 understood available information on the pandemic would know what to do or questions to ask if they or someone else contracted sarscov2 have access to healthcare were they to become ill with sarscov2 infection and would be able to cope with extended containment measures such as a lockdown compared to south africa more respondents in india reported concern over infection its financial implications and associated stigma on the intent to wear a face mask 86 and 262 of respondents in india and south africa reported dissatisfaction with this measure while outdoors respectively there was no association between hand washing and water supply as even those without access to water supply reported that they washed their hands more frequently since the pandemic water supply showed a mixed relationship with employment as some fulltime workers had no access to water the test highlights a difference between participants in the two countries p 00008 and 04471 for india and south africa respectively among survey respondents in south africa we noted a significant difference in vaccine acceptancehesitancy between those who indicated that they practice hh more often since the pandemic compared to those who indicated that there has been no difference in their hh practices since the pandemic there was also a significant difference in vaccine acceptancehesitancy between those who were and were not vaccinated against the influenza virus across both countries there was a significant difference in vaccine acceptancehesitancy between selfemployed individuals and students our results show that some respondents avoided healthcare facilities during this pandemic some participants in this study reported avoiding healthcare facilities because of a fear of contracting the covid19 virus employment status did not seem to have a significant relationship with this fear although more of a case could be made for south africa as it had a lower pvalue than india s2 data while the pvalue was still too low to be considered significant there were less south african participants than indian participants therefore with more data this relationship may turn out to be significant discussion this study provides insight into the publics awareness and perspectives of the sarscov2 infection risks and preventive practices in two middleincome countries hard hit by the pandemic 10 the aim was to gain some understanding of knowledge and views about the pandemic particularly when considering the expected roles that the public have in this pandemic regarding social distancing and infection prevention through hand hygiene mask use and vaccination uptake the sampling shows a major skew of respondents towards india we believe that use of the paper version of the form in india allowed the research team in india to personally engage with potential participants which may have influenced and increased the participant pool in india while the intention was to collect data with increased representation across both countries this was not readily achieved the survey invitation was distributed through the network of the researchers who are largely healthcare workerssome of whom were involved in the pandemic response majority of the respondents to this survey of patients and the public were resident in the province or state where the research team worked as such the results discussed here are not necessarily representative of views from residents of the two countries at the time of the study these two countries were at different phases of the pandemic infection curves with no viable vaccines available although these data are somewhat dated these findings add to the body of knowledge on the publics perceptions of the pandemic they also provide information that can be leveraged for improved infection prevention and behavioural interventionsfor this and future infectious disease pandemics such knowledge will be helpful in infectious disease pandemic control and mitigation including in the ongoing covid19 pandemic the insights from this study can assist with measures to address continued vaccine hesitancy and inequity when many countries are dealing with a fourth or subsequent infection wave table 3 relationships between selected variables india south africa query yes no na pvalue yes no na pvalue from the onset of the pandemic efforts have been communicated to inform the public of infection risks and required containmentmitigation measures the predisposition of an individual to comply with infection prevention measures depends in part on their awareness of infection risks the need for public engagement and hygiene intervention behaviour change and consideration of sociocultural aspects in public awareness initiatives in india and south africa has been noted in the literature 15 16 17 18 19 participants seemed quite knowledgeable about the covid19 pandemic with most correctly identifying infection sources risks and symptoms this could be from the volume of news media dedicated to the pandemic which may also have served to provide education and awareness among the public survey respondents demonstrated awareness of the pandemic with most identifying the primary routes of transmission incubation period symptoms of infection and recommended measures for infection prevention and management of mild conditions including the reason for and duration of isolation information on the pandemic was generally gained from traditional and social media family and friends and government websites respondents reliance on general and social media as sources of pandemicrelated information highlights the role played by the media in pandemic containment and mitigation there was no significant association between positive predisposition to infection prevention measures and sociodemographic factors in contrast with findings in previous studies perhaps because our sample was biased towards the highly educated 2021 the information landscape has changed extensively in the last three decades prompting the need to address not only the sarscov2 pandemic but also its related infodemic 22 while the main aspects of an infodemic refer to inaccurate and misleading information shared through digital and physical environments during disease outbreaks disinformation refers to the deliberate spread of false information in this pandemic we are increasingly witnessing a growing infodemic driven by misinformation including a worrying trend in the escalation of disinformation through social and digital media 23 24 25 the role of the media traditional and digital alike in framing and rapidly disseminating information is evident in this pandemic particularly when related to influencing behaviours and empowering individuals with the accurate information to make informed decisions regarding ipc 22 26 27 28 family and friends were noted as sources of sarscov2 information by respondents in the survey word of mouth presented facetoface or through various communication channels within families and among friends though not specifically a media source is an essential source of information it is also a key route for spreading misinformation mainly because of the trust between the source and the recipient thus the prominence of influencers in disseminating pandemicrelated information is highlighted the findings of this study underscore the importance of various media as sources of information for informed decisionmaking among the public it also draws attention to the relevance of social media and family and friends as sources of pandemicrelated information for the public given the infodemic that has trailed the sarscov2 pandemic on all media 2829 there is a need for evidenceinformed and timely communication in continually addressing pandemicrelated misinformation and disinformation infodemic management is multifaceted requiring different disciplines to address it beyond communication factors influencing an individuals behaviours may relate to external pressures including the economy education health literacy cultural or other beliefs 30 which may be helpful to explore in further studies some respondents in this study considered sarscov2 to be foodor waterborne such beliefs may impact infection prevention measures while there has been research into transmission by these routes 3132 they have not been noted as primary transmission routes for the viral infection droplet and airborne transmission have been noted as some primary transmission routes with the use of face masks a significant intervention in reducing the spread of the infection 3334 across both countries some respondents expressed some level of reluctance to maskwearing despite their concern about contracting the infection which may be related to the stigma or discomfort of masks stigma known to influencecompromise infection prevention behaviours 3536 needs to be addressed locally and globally not only for the current pandemic but also for future ones to improve adherence to optimised infection prevention practices among other options to reduce infection risk hand hygiene has been prioritised in public health messages for pandemic mitigation 37 access to clean water is critical for hand hygiene and is among the tools to address and mitigate the impact of the pandemic as highlighted in the literature 3738 there was no relationship between awareness and practice of infection prevention measures and sociodemographic factors such as employment status or availability of amenities while infection prevention measures such as hand hygiene and physical distancing may pose a challenge in some lmic especially in underresourced sections of rural areas or densely populated urban settings 3738 water supply did not affect hand hygiene frequency among our survey respondents isolation and quarantine of infected and exposed individuals are underlying measures for infectious disease control though this may prove challenging responses to sarscov2related isolationquarantine duration reflect respondents perceptions of sarscov2 incubation while there was an initial consensus on a 14day isolationquarantine period for infectedaffected individuals there have been shifts and debates on the optimum incubation period of the virus hence the duration of isolation and quarantine measures 39 respondents responses reflected this more so in india where discussions about extended isolation periods have been reported 40 lockdown measures instituted in various parts of the world following the spread of sarscov2 served as another infectious disease mitigation strategy with the rise of infection transmission and the attendant lockdown measures it was expected that individuals would have avoided visiting healthcare facilities some participants in this study reported avoiding healthcare facilities because of a fear of contracting the covid19 virus with current data it couldnt be concluded that this was influenced by employment status although a case could be made for south africa as it had a more significant relationship than india despite there being less south african participants than indian participants employed participants may be more likely motivated to maintain good health or hesitant to confirm illness for fear of losing money or work resulting in fewer visits to healthcare facilities than those unemployed while lockdown measures can reduce patient presentation to healthcare facilities 4142 such a decline in presentation may also be associated with later presentations with more severe consequences initiatives are required to address gaps in patient care necessitated by public health promotion strategies such as lockdowns in this and future pandemics across the two countries attitudes to covid19 vaccination were positive however the country analysis showed this was driven by higher vaccine acceptance in india with respondents in south africa more cautious regarding covid19 vaccination the significant difference in vaccine acceptance hesitancy between those who were vaccinated and those who were not vaccinated against the influenza virus has been reported in another study where knowledge of covid19 vaccination was noted to be associated with past experience of vaccine uptake 43 reasons cited for hesitancy or a negative attitude to sarscov2 vaccination were related to mistrust in the vaccine development process and the futility of vaccines for what respondents considered a selflimiting flulike illness this survey was however conducted before sarscov2 vaccines were available perceptions and attitudes may have changed in the time since the survey was conducted hesitancy towards the sarscov2 vaccine had been noted earlier in the pandemic fuelled by the circulation of sarscov2related conspiracies 4445 and associated with various sociodemographic and other factors 46 47 48 the notion that the pandemic has been grossly exaggerated and reported with unnecessary financial and other stresses on populations was expressed by some participants who provided additional free text information across both countries as the pandemic evolves research to better understand infection and vaccinerelated concerns among the general population is needed to support targeted and contextually appropriate strategies promoting vaccine uptake and optimised infection prevention behaviours among individuals with opposing opinions about vaccination application of social science methods to study underlying reasons and contexts for their views along with highlighting the individual rather than the collective advantages of vaccination may provide helpful and relatable insight 4549 this could be particularly important when considered in light of recent research and noted factors that may influence vaccine perception and uptake 45 46 47 48 49 50 more recent research has provided insight into dealing with vaccinehesitancy as well as the challenges associated with antivaxxers 4548 public health campaigns and vaccination promotions should therefore understand and leverage social listening techniques to comprehend public perceptions concerning communication gaps a similar method of social listening should be developed for community and traditional settings to understand why various beliefs and behaviours related to covid19 emerged strengths and limitations our study provides unique insights into the publics attitudes and practices across two lmic during the early stages of this pandemic the findings are subject to some limitations which should be considered in the interpretation first being a crosssectional study it cannot be used to determine temporal relationships in addition the relevance of the findings may change over time and with interventions especially as subsequent waves of covid19 have been reported second the online distribution of the survey and the limited paper version may have limited its reach particularly underrepresenting individuals from diverse socioeconomic levels in addition data collection across both sites did not rely on the same methods given the covid19 restrictions at the time of data collection which likely influenced the sample sizes across the sites survey respondents are therefore not representative of the public in either of the two countries limiting the generalizability of findings we utilized covid19 vaccine uptake views as a proxy for pandemic awareness when looking at perceptions and awareness some questions in the survey were related to this there plos global public health may not have been a simply way to amalgamate them to categorise participants in levels of either our assumption was that if people were willing to take the vaccine then they were aware of why the vaccine was necessary as they perceived it as something positive whereas if someone was unwilling to take the vaccine they were assumed not to be aware of its importance and therefore have a low level of covid19 perception and awareness of course with this assumption certain groups of people will be misclassified an example could be those who are covid19 aware but refuse the vaccine for religious reasons on the other hand there may also be those that have no knowledge of covid19 but are willing to get a vaccine only because they understand the need for a vaccine and not necessarily because they understand the dangers of covid19 there isnt always a fine line between perception and awareness and so the binary question was used to encapsulate the topics and produce a workable statistic nevertheless this paper fills a gap in the knowledge awareness and attitudes of a section of the public in india and south africa towards ipc practices in the context of covid19 within the first year of the pandemic it will be beneficial for charting public understanding and perception of the covid19 pandemic and provides informative data that can be employed for public engagement in other infectious disease control and mitigation efforts across both sites and similar contexts the skew of respondent sample towards the highly educated and those in contact with healthcare services or professionals means that while findings are biased they are likely to provide a reasonable picture of the best case scenario as these respondents will likely be more knowledgeable and better informed than the average general respondent while this research presents the data for each country separately it is not its intention to make any statistical comparisons between participants in the two countries despite that the individual test on how employment affects water supply provided some insight on differences between participants in the two countries thus the need for pandemic mitigation efforts to consider differences in context and subjects for the delivery of contextspecific and appropriate interventions is highlighted recommendations this study presents socioeconomic and demographic data which may influence public awareness and behaviour and further be explored in pandemic mitigation initiatives among the public in both countries survey respondents correctly identified public health promotion measures for sarscov2 reported disinclination to maskwearing and reported hesitancy for the uptake of sarscov2 vaccination highlight gaps that can be addressed for improved pandemic mitigation efforts while the data is not representative of participants across both countries further research to explore the outlook towards mask use and vaccination across both countries can provide more insight on factors influencing infection prevention and vaccine hesitancy vaccination campaigns should consider robust public engagement and more targeted communication strategies using tactics like social listening with multimodal participatory online and offline initiatives to engage academics health care providers and the society in curbing the pandemic

a crosssectional survey among participants in india and south africa to explore perceptions and awareness of sarscov2related risks main outcome measuresproportion of participants aware of sarscov2 and their perception of infection risks as it related to their views and perceptions on vaccination ie using covid19 vaccine uptake as proxy for awareness level selfadministered questionnaires were used to collect data via weband paperbased surveys over three months pearsons chisquared test assessed relationships between variables a pvalue less than 005 was considered significant there were 844 respondents india n 660 south africa n 184 response rate 876 with a 611 vs 383 female to male ratio posthighschool or university education was the lowest qualification reported by most respondents in india 773 and south africa 793 sources of pandemic information were usually media and journal publications 732 social media 646 family and friends 477 and government websites 462 most respondents correctly identified infection prevention measures such as physical distancing mask use with 900 reporting improved hand hygiene practices since the pandemic hesitancy or refusal to accept the sarscov2 vaccine was reported among 179 and 509 of respondents in india and south africa respectively reasons cited included rushed vaccine development and the futility of vaccines for what respondents considered a selflimiting flulike illness in south africa vaccine acceptance was associated with improved hand

introduction housing is a crucial need everywhere in the world shelter is one of the 3 basic human needs that must be met in addition to food and clothing needs a place to live or a house is necessary for living human life and daily life thus the house is not only interpreted as a place to live alone but the ownership of a house or land is considered an investment item in the long term the house is also often used as a benchmark for human welfare someone can buy a house in cash if that person has money whose value is equal to the price of the house however along with the many demands that must be met by the community buying a house in cash is increasingly difficult to do banking is an institution that bridges people who need funds and people who have excess funds funds channeled by the banking sector are obtained from public savings meanwhile the amount of peoples savings is determined by the amount of peoples income the reality is that many people still have not been able to prosper in their lives due to low incomes so they are increasingly unable to own a house as expected therefore one alternative to owning a home is through a housing loan in general prospective homeowners are reluctant to borrow loans from financial institutions because of the stringent requirements for access and affordability of loans finance is the main obstacle to owning housing loans therefore to respond to this condition the indonesian government adopted a policy so that people especially the lower middleincome group can have decent and affordable housing with their purchasing power by providing housing credit facilities this is where the role of banks in supporting economic activity is enormous one of the credit facilities needed by the community is the provision of housing loans in 2012 north kalimantan province was officially formed as the 34th province in indonesia as one of the youngest provinces in indonesia north kalimantan province cannot be separated from development efforts for the welfare of its people through the office of public works spatial planning housing and settlement areas north kalimantan province has a mission to provide the development of settlement facilities and infrastructure to create decent healthy and affordable settlements thus kaltara province is also inseparable from government policies that assist homeownership for lowclass people by distributing various credit facilities especially mortgage loans according to data from the central statistics agency for north kalimantan province the population of north kalimantan province in 2015 was 641936 people in 2016 there were 666333 people in 2017 there were 691058 people while in 2018 there were 716047 people and finally in 2019 there were 742245 people it can be seen that the population of north kalimantan province increases every year but this is inversely proportional to home ownership in the province according to the bps of the republic of indonesia the proportion of households based on their home ownership status has fluctuated over the last five years from 20152019 figure 1 shows the percentage of house ownership based on ownership status the most significant percentage is in the status of owning a house then the status of the contractlease and finally others for four years namely in 20152018 the ownership of houses with selfowned status has continued to decrease and in 2019 the percentage increased again this is a question of what causes fluctuations in home ownership with their status in the province of north kalimantan which has continued to decline for four years inversely proportional to the number of residents who have increased yearly supposedly an increase in population will increase the demand for housing the national socioeconomic survey for health and housing modules conducted by bps produced data on the percentage of households with selfowned housing status and the purchase method figure 2 shows that in 2016 the most significant percentage of how to buy a house namely by cash percentage of 6058 percent in second place is the nonmortgage installment method and the following position in other ways and mortgage installments meanwhile in 2019 the most significant percentage was still for buying houses by cash namely 7351 percent nonmortgage installments of 1431 percent and mortgage installments of 1218 percent between 2016 and 2019 there has been a change in how people obtain home ownership starting with cash purchases and installment mortgage purchases which have increased in 2019 however on the contrary the method of purchasing nonmortgage mortgages and others decreased in 2019 literature review demand theory the optimal choice of consumers in requesting goods and services depends on the consumers income and the price according to loanable funds theory in principle the cost of borrowing or the price paid for borrowed funds is the interest rate in the credit market the demand for credit is influenced by household income and the cost of credit that is the additional costs incurred by households when taking creditloans in some situations a persons preference can also affect the consumption of an item to get maximum satisfaction a person will prefer to consume or not consume one item therefore a persons demand for an item is a function of price income and preference previous research one main factor influencing customers in choosing a bank or housing finance company is the interest rate in various countries housing interest rates are a persons primary consideration in taking credit low housing loan interest rates can attract someone to take credit the interest rate as the price in demand for credit shows that if the price goes down it will increase the demand for credit sandria et al khoirudin and ganthari syafri found a negative relationship between interest rates and the decision to take housing loans even in saudi arabia housing with zero percent interest rates is a unique attraction the risks involved when taking credit make credit with fixed interest rates a particular preference in influencing the decision to take credit a persons decision to take credit housing can also be measured by the income he receives sandria et al used time series data and found a significant favorable influence on customer demand for home ownership loans in palembang likewise ariyanti kusumah and sughana sheela found that income can increase the demand for credit housing it differs from ganthari syafri who use per capita income to see the effect on housing ownership and find that increasing per capita income will increase the desire to buy or invest in home ownership apart from economic factors according to kotler et al other factors that influence the decision to take credit are as follows 1 cultural factors 2 social factors an 3 personal factors sughana sheela analyzed the decision to take housing loans in visakhapatnam india she found that most respondents who took housing loans were married and had permanent employee status in the business context the large number of workers positively increases business income meanwhile in the household context the increasing number of working household members is expected to increase household income and through increasing household income will increase the decision to take housing loans age dramatically determines ones mindset generally the higher the age the more mature the mindset this mindset influences a person to invest by deciding to take a housing loan in general a strategic location easy road access and close to city markets are the most critical factors in influencing demand decisions for housing the high demand for housing in urban areas due to urbanization has increased the demand for housing the concept of utility can also explain a persons preference for consuming an item to obtain satisfaction in this case the preference for taking housing loans therefore from the above literature study the following research hypotheses will be developed what are the economic factors which consist of household income variables per capita income and housing loan interest rates social factors consisting of variables of the employment status of the head of the household demographic factors consist of the age of the head of the household the number of working household members and marital status as well as geographical factors consisting of the location of the household influences the households decision to take housing loans in north kalimantan data and research methods this study examines the relationship between the factors influencing household decisions to take housing loans the data used in this study is secondary data namely microdata from the september 2019 national social and economic survey and data from bank indonesia the objects studied were households with a sample of 514 households in north kalimantan the decision to take housing loans a households decision to take a mortgage is also influenced by household income prices and the preferences of someone who can encourage them to take a mortgage households will take housing loans from credit sources i if and only if the utility derived from it is more significant than all other sources of credit which can be selected u u u y u y ij ik ij i i j i k i ik n n u y u y ij i i k i ik ij n n in general it can be generalized to u z z z ij j j nj ij 1 2 n equation can be written as u z ij ij ij n where uij is the utility obtained by household i from taking sources of credit j zij is a systematic component representing household utility i in taking credit j ij n is a random variable that takes into account unexceeded factors households will choose the alternative that provides maximum utility in cameron trivedi household probability in determining choices when taking housing loans j if and only if pr p b u u k j ij ij ik 6 2 q h the decision of households to take housing loans in this study is based on the decision to take housing loans or not to take housing loans logit method this study uses the logit regression method logit regression is due to the condition of the dependent variable which is qualitative or binary in general the logit model aims to find the probability of an event this study uses the logit model to find opportunities for a household to take a mortgage or not mathematically it is stated that the possibility of a household taking a mortgage or not v e e e 1 1 1 i z z z i w where z x i i 1 2 b b prasetya b o what makes north kalimantan residents take housing loans if vi w is the probability that an event occurs then the probability that the event v 1 i h w does not occur or that the household does not take housing credit is v e 1 1 1 t zi w the above equation can be written as p p e e e 11 1 i i z z z i i i 8 p p e 1 i i zi is the odds ratio of an event namely the ratio of the probability of an event occurring to the probability of not occurring in this study what is meant is the ratio of the likelihood of households taking mortgages to households that do not take mortgages if equation is converted to a natural logarithm the following results will be obtained ln l p p z x 1 i i i i i 1 2 b b e li is the probability ratio that is not only linear in xi the parameter li is called logit so the logit model is contained in equation marginal effect some researchers also use the value of the marginal effect to help interpret the value of the marginal effect can measure the effect of changing one unit of the independent variable on the probability of the i category thus the value of the marginal effect can provide a better understanding of the logistic regression model the marginal effect shows changes in the dependent variable when certain independent variables change whereas other independent variables are considered constant the general form of the marginal effect value for xi in the multinomial logistic model is x p p p p j j j j k k k j j j 0 d d b b b b 8 6 b where j b is the regression coefficient of the independent variable or the j th slope therefore in this study the value of the marginal effect will be used in interpreting the regression results this studys decision to take housing loans includes public housing loans and nonkpr loans therefore the analysis model in this study can be written as follows ln p y x p y x income capita interest djob work age dmarital dlocation 0 1 i i i i i i i i i i 0 1 2 3 4 5 6 7 8 b b b b b b b b b f d n 11 the description of each variable both the dependent and independent variables in the model can be seen in the table below finding and discussion overview table 2 shows that the average income of households that take housing loans is greater than that of households that do not this shows that the greater the income the greater the tendency for households to take housing loans in contrast the table shows that the average per capita income of households that do not take housing loans is more significant than those that take housing loans this shows that if a household has a higher per capita income it will tend not to take housing loans furthermore the average housing loan interest rate for households that take housing loans is more significant than for households that do not this shows that the higher the interest rate the greater the tendency for households to take housing loans the interest rate may be the price that must be paid when taking a loan so that if a household is able willing to pay that price the household will tend to take credit on the other hand if a household is unable unwilling to pay the fee it will decide not to take credit the average number of household members who worked on the decision to take housing loans was more significant compared to the average number of household members who worked on the decision not to take housing loans this shows that the more household members with income the more likely they are to take housing loans because household income will increase the average age of households who took housing loans was higher than those who did not the older the household head is the more inclined to take housing loans this is due to the ability to accumulate higher income so that it will be more able to take housing loans table 3 shows that households with a head of household as an employee are more likely to take housing loans than households whose status is other than an employee this makes it possible for employees to have monthly income so that when applying for a housing loan they are more likely to be approved because they are considered capable of paying the installments every month especially if they have permanent employee status households with singleunmarried status tend to take housing loans compared to households with married status this is possible if the status of a married household has a significant expenditure making it challenging to take housing loans furthermore households in urban areas also have a more significant percentage of taking housing loans than those in rural areas this is possible because households in rural areas tend to build their own houses after all raw materials for houses are more accessible and widely available in rural areas result this section discusses the research results and empirical discussion of the logistic regression model ─ logit regarding household decisions to take housing loans in north kalimantan the empirical results of the logistic regression ─ logit model are presented based on table 4 the logistic regression ─ logit results of households decisions to take housing loans in north kalimantan show that the value of count r2 is 0778 it can be interpreted that this model which includes economic social demographic and geographic factors is an independent variable that can explain the dependent variable namely the decision of households to take housing loans in north kalimantan by 7780 percent in contrast the others are influenced by other variables outside the model table 4 shows that the household income variable significantly positively influences household decisions to take housing loans with an me value of 000002 it can be interpreted that for every increase in household income of idr 1000 then the probability of a decision to take a housing loan is 000002 percent this is in line with demand theory the more an individuals income increases the more their purchasing power will increase increasing the demand for an item this result aligns with the research of ariyanti kusumah and sandria et al who found a positive effect of customer income on demand for simple housing and home ownership loans on the other hand the per capita income variable significantly negatively affects household decisions to take housing loans although increased household income will increase the decision to take housing loans the preferences of households in north kalimantan may change if they perceive that they have a high enough income according to the 2019 housing statistics publication households in north kalimantan tend to build their own houses compared to other methods especially in rural areas this result is inversely proportional to the research results of ganthari syafri which found significant positive results per capita income on demand for housing loans the last economic factor is the interest rate variable this variable significantly influences the decision to take housing loans with an me value of 003124 it can be interpreted that for every 1 percent increase in interest rates the probability of a households decision to take housing loans increases by 003124 percent this result is inversely proportional to the loanable fund theory where increasing interest rates will reduce the demand for credit the literature review chapter shows that interest rates are costs incurred on borrowed funds it can be interpreted that if someone is able or willing to pay the loan costs they will take a loan because these costs will be dependents that must be paid in line with the credit taken conversely if the person is unable or unwilling to pay the fee the person will not take credit therefore this studys results indicate households ability to repay borrowing costs the higher the ability to pay loan costs the higher the decision to take housing loans this result is different from khoirudin research which found a significant negative relationship between interest rates and homeownership loans the creditor will look at the debtors financial ability to provide credit in the banking world there is an analysis principle known as 5c in giving credit one of these principles is capacity which looks at the ability of the debtor to repay the loan the regression results show that the variable household head employment status positively influences the decision to take housing loans this is possible because the status of the head of household as a staffemployee is deemed capable of paying the loan installments which are generally paid every month after all the employeeemployee has a regular monthly income according to bajaj finance ltd a job status that has a regular income will be preferred by borrowers in other words it will be easier to get a housing loan therefore this can influence the households decision to take housing loans because it is likely to be approved by the lender this result is in line with sughana sheela which found a significant positive relationship between permanent employee variables and someones decision to take out a housing loan because permanent employees are considered capable of paying monthly installments the first demographic factor is the number of working household members however these variables do not significantly affect household decisions to take housing loans furthermore the age variable of the head of household has a significant favorable influence on the decision to take housing loans older age is considered more secure and can accumulate higher income higherincome will increase the decision to take a housing loan this result aligns with a study by patil et al and sughana sheela who found that someone aged between 3140 years is more likely to take out a home loan than those under their age the marital status variable significantly positively influences the decision to take housing loans it is possible that unmarried people do not have many dependents so they are more likely to take housing loans which can be used as investments in the future this result differs from the findings of sughana sheela that married people tend to take homeownership loans compared to unmarried people because a home is a primary need if they are married the last factor that influences a households decision to take a loan is where the household is located the regression results table shows that this variable significantly influences household decisions to take housing loans with an me value of 020209 every 1 percent increase in urban households will increase the probability of households taking housing loans by 02 percent this shows that households in urban areas prefer housing credit to those in rural areas this possibility occurs because households in rural areas prefer to build their own houses rather than buy from developers in cash or on credit the availability of raw materials for houses at a lower price and the cooperation between residents when building houses make this possible another possibility is that urban areas are more strategic for building housing according to sembiring sunargo the more strategic the housing location the higher the demand for housing therefore developers prefer building housing in urban rather than rural areas conclusion this study found that household income interest rates employment status age of head of household and location of residence have a significant favorable influence on household decisions to take housing loans meanwhile per capita income and marital status significantly affect the decision to take housing loans the small number of samples used makes the effect of a significant variable similar between one category and another for example the or value of the household income variable on the decision to take housing loans is only 100015 times compared to the decision not to take housing loans these results indicate that the effect of household income on the decision to take a housing loan is almost the same whether the decision to take a credit or not several other variables also give similar results however the location variable shows different results the or value of the location variable where the date is located is 362 it can be interpreted that households in urban areas have a 362 times probability of taking housing loans compared to those in rural areas this shows the location variable where the date is the most significant determinant of whether a household will take out a housing loan limitations and suggestions the limitations of this study are only analyzing one point namely 2019 for further research time series data can be used so that the influence of the variables used can be more indepth to analyze household decisions to take housing loans especially trends in loan interest rates

housing is one of the human needs that must be met many ways are used to get the required residence house one of them is by taking a housing loan various factors can become obstacles in taking housing loans this study used logistic regression logit and took a sample of 514 households in north kalimantan province this research will examine the influence of economic social demographic and geographic factors in household decisions to take housing loans the results showed that household income interest rates hoh employment status hoh age and household location had a significant positive effect in contrast income per capita and marital status had a significant negative effect meanwhile the number of hm working had no significant effect of the variables used the household location variable influences a households decision to take housing loans with an or of 362

introduction according to the 2020 open doors report published by the institute of international education more than 1 million international students were enrolled in us universities in the 20192020 academic year a number of themespecially graduate students since they are older in age than undergraduateswere probably accompanied by family a decade ago chittooran and sankargomes estimated that a third of international students bring their families with them despite their high numbers lee and rice discovered it isnt uncommon for international students and their families to report being treated like uninvited guests underlying factors for such experiences could include international students being perceived as threats to us economic selfsufficiency or being viewed as mere sources of revenue which then discounts their cross cultural experiences or even neoracismwhich spears defines sen fcomm as the subordination of people of color on the basis of culture which could create barriers to forming interpersonal relationships in the host society international students spouses whom de verthelyi called invisible sojourners are worse off in addition to having no work opportunities in the us due to visa regulations they are generally ignored by university authorities who do not see their wellbeing as falling within the universitys realm of responsibility thus these individuals are in sic the community they are not of sic it this negligence on part of university administrators continue despite research revealing that accompanying spouses are a potentially key source of social support for international students and play a crucial role in their academic success and acculturation incidentally international students contributed more than 38 billion to the us economy during the 20192020 academic year besides their dollars they also bring their skill and knowledge often in the areas of science technology and engineering the researcher of this paper was an international student at a large midwestern university in addition to the issues mentioned above he noticed his married peers struggling to afford and access adequate healthcare for their accompanying spouses and families at the time when this study was conducted there was no communication platform where international students could clarify their queries or voice their struggles regarding healthcare affordability although such a communication channel could well serve as the first step to addressing their needs to therefore give these individuals a place to communicate their opinions the researcher did a graduate schoolfunded white paper that forms the basis of this paper spouses of international students are an underresearched population the purpose of this paper then is to give these individualsas well as their enrolled partnersa discursive space to communicate their struggles in accessing something as basic as adequate healthcare the research question that this paper will address is the following rq what are the barriers that married international graduate students face at university x in the midwest while trying to get adequate health insurance andor healthcare for their families • what strategies do they employ to procure medical help in spite of the barriers • what possible interventions did they suggest to improve the healthcare facilities available to families and spouses of married international graduate students at university x literature review problems of graduate students with families even before one begins to discuss the problems that married graduate studentsa specific subset of the graduate student populationface it is important to analyze the position of graduate students per se within the context of higher educational institutes santiago et al in their study of brown female teaching assistants called graduate students lowlevel wage earners in a corporate enterprise where universities over the past few decades have turned themselves into transnational institutes of knowledge production change distribution and consumption in this financiallydisadvantaged position graduate students often experience exploitative practices at the institutional level with their voices silenced that further depowers them with that in mind it is scarcely surprising that research has revealed the struggles graduate students with families go through juggling myriad rolesthose of a student parent partner employeein addition to dealing with financial insecurity and career uncertainty as well as managing their relationship with their academic adviser rahman in his qualitative study on graduate students with families at a university in california found his interviewees mentioning balancing between school work and parenting to be a particular challenge and also expressing guilt at spending inadequate time with their families his respondents also voiced their dissatisfaction with the student services available to them revealing needs for counseling training in timemanagement and more targeted communication between departments and graduate students oswalt and riddock in their survey of graduate students14 of whom had childrenat a large southeastern university found that while their survey respondents reported high levels of stress with school work finances assistantships and jobs and wanted to access healthy coping strategies through the university they were nevertheless unware of some of the services already available to them on campus this is similar to what brown and nichols found in their research regarding pregnant and parenting studentsa lack of awareness about available oncampus resources they also found a large gap between what is being provided and what is actually needed in fact brown and nichols based on interviews with their research subjects called for policy changes that could lead to for instance mentoring of faculty to cater to the needs of pregnant or parenting students or the need for a dropoff daycare facility oncampus they advocated for the creation of administrative policy at the university level that would change the organizational culture and help universities create programs and policies that would help pregnant and parenting students the needs of international students and their spouses some of the key studies amid the very limited literature on international students spouses include vogel study of japanese wives of harvard university students which revealed a variety of problems including those of language barrier social isolation pervasive anxiety difficulties with adjusting to american social customs and communication problems between japanese students and their spouses and healthcare professionals because of the language barrier as well as the students unfamiliarity with the role of nurse practitioners and the american insurance system de verthelyi in her study involving spouses of international students at a large university in rural virginia discovered additional issues which spouses of international students reported facing such as frustration stemming from a lack of purposeful activities to do a loss of professional identity as spouses are prohibited from working due to visa regulations and financial restrictions and instability wives of students also figure out that in a very practical sense their participation in university life is severely limited when they have problems they cannot automatically expect to use school resources and usually do not know how to get linked to community resources myerswalls et al in their study of 31 international graduate students and spouses listed among six categories of stressors the anxiety some students reported experiencing regarding their spouses not having health insurance coverage in the us this reflects a persistent problem since one of the earliest comprehensive studies done by the national association of foreign student advisers in 1981 about the needs of international students placed the need for having enough money for basic living expenses was right at the top of the list and the need for enough money for necessary medical care as the fifth item on the list in spite of three decades having passed since that study both the abovementioned need has not been met at the time this research was being done a graduate student at the university where this project was conducted was earning 13322 a year if she was a teaching or research assistant or 14630 if she was a graduate lecturer the year before the federal poverty guidelines pegged the minimum annual income of a family of three at 19090 thus at the university where this research was done an international married graduate student who lived with her spouse and child could only live below the poverty line not much has changed since the time when the white paper was written for the academic year 20212022 according to the graduate staff employment manual of the university where the research was done a graduate teaching or research assistant was receiving a minimum of 15912 if she was working halftime the longest duration an international student is allowed to work per week during school year if she was a graduate lecturera rank higher than a graduate teaching or research assistantworking half time she would receive 17474 during the academic year however the us federal poverty guideline for 2021 said a family of two had to make more than 17420 to live above the poverty line a family of three had to earn 21960 an international graduate student with a spouse at this university was thus living below the poverty line if she was a teaching or research assistant and close to the poverty line is she was a graduate lecturer if she had a child then the family of three was most certainly living below the poverty line consequently affording health insurance is difficult at this university a single graduate student working halftime would pay at least 251 per month if she added her spouse to her insurance and at least 331 per month if she added her spouse and child to her health insurance for an individual earning about 1480 a month as a graduate assistant paying 331 a month for health insurance for her spouse and child is a hard choice since it leaves her with 1150 to pay for food rent and other miscellaneous costs the situation was far worse for an international student who had no funding or who worked 20 h a week she paid 1135 annually for her own insurance but the yearly amount rose to 4985 if she added her spouse to her insurance plan or 6386 if she added her spouse and a child to her insurance plan if she wanted to add more than one child and her spouse to her insurance plan the annual payment escalated to 6790an exorbitant amount for one dependent largely on her own funds in spite of the persistent nature of the problem of accessing healthcare with limited funds no studies have exclusively looked into how international students and their spouses negotiate the problem of their financial limitations restricting their access to healthcare nor has any study provided a discursive space where international students and their spouses could articulate ways in which a recalcitrant problem of this nature could be redressed this current study could be a step toward fulfilling that gap in the literature theoretical framework since this paper explores the barriers to healthcare access that spouses of married international students faced at a particular midwestern university where they were a minority group this study used the theoretical framework of the culturecentered approach to health communication which provides a lens for analyzing and interpreting the lived experiences of minority communities as well as seeks to create discursive spaces where minority voices can be heard articulating their needs as well as proposing solutions this is exactly what this study does by listening to the rarelyheeded opinions and suggestions of international students and their spouses building upon subaltern theory that proposes that historical economic and ideological forces silence marginalized communities by imposing a one size fits all set of values offered by the dominant paradigm the cca posits that marginalization takes place through systematic institutional mechanisms that are invisibly enacted through the ideologies of the health care system as a result the subaltern sectors are rendered absent from the dominant spaces of knowledge this absence is seen in case of spouses of international students as we have discussed earlier the cca then aims to mitigate these asymmetries of power in the context of health inequalities and redress the concomitant erasure of voices of marginalized communities by creating discursive spaces where these voices can be heard incidentally the cca posits that communication exists at the intersection of culture structure and agency according to sastry et al in the context of cca culture refers to the dynamic webs of shared meanings that are constituted through everyday interactions among cultural members within their local contexts structures appertain to institutional roles rules practices and ways of organizing that constrain and enable access to resources in this study structures would include medical services available at the community level andor on campus they also would include healthcarerelated policies at the university that impacted the lives of students by agency one refers to the capacity of human beings to engage with structures that encompass their lives to live within these structures and at the same time to create discursive openings to transform these structures in the context of this research project married international students and their spouses were considered as belonging to a marginalized group not only due to their meager income but also because their opinions are rarely sought or heard within the mainstream discursive spaces of the american academe also because international students and their families typically come from societies vastly different from mainstream america using a theory that valorizes the role of culture in understanding the articulations of health experiences in marginalized communities was considered appropriate for guiding this paper methods focus groups and indepth interviews were used to gather data in this study they were considered appropriate for this study because first this study is undergirded by the theoretical underpinnings of the culturecentered approach to health communication which aims to open up discursive spaces for marginalized voices to be heard it was therefore appropriate to use a datagathering method such as focus groups and indepth interviews that would allow those voices of the marginalized to emerge although the intention of the study is not to create a theory nevertheless the principles of constructivist grounded theory has been used to do a thematic analysis of the data since the cocreations of meanings through the researchers conversations with the participants via the focus groups and the interviews have been examined here setting this study was conducted at a large midwestern university and was funded by a graduate school grant that was awarded to projects focused on addressing some problem of graduate student life with the intention of making improvements incidentally this university has a record of being among us universities with the largest international student populations in 2022 it is among the top 10 this is a significant fact because although the setting is a location where international students are numerically significant in the campus community yet knowledge of their struggles to afford healthcare for their spouses has eluded the authorities this then further raises the question that if this problem could persist where international students have a robust presence what might be the plight of international students spouses on campuses where they are fewer in number and therefore all the more negligible in presence and importance the researcher as stated earlier was an international graduate student at the university where this research project was conducted from his interactions with fellow international students who were married he was aware of the problems those students were facing affording health insurance for their spouses but he wanted to explore the problem deeper and doing focus groups seemed to be an appropriate starting point followed by a series of indepth interviews data collection and recruitment strategy data collection for this study was done in twophases in the first phase a series of three focus groups were conducted oncampus information gathered during these focus groups informed the questions that were subsequently asked during indepth interviews that constituted the second phase of datagathering recruitment for this project was done in a number of ways the office of international students and scholars sent out a recruitment email to all international students on campus flyers also were posted around campus both the recruitment email and the flier specified that participants had to be either international graduate students who had spouses andor children living with them or they could be a spouse of an enrolled international graduate student purposive sampling was also used to contact some married international students who the researcher personally knew these individuals were included in the study because they had their spouses and families residing with them subsequently those interested contacted the researcher and was told to come to a specific room on campus at a particular time and date each focus group had 5 to 6 participants the researcher was there to welcome participants to the venue read out the irbapproved consent form and get their consent signatures each focus group was recorded using a digital voice recorder with the participants consent the indepth interview participants also contacted the interviewer directly the oneonone interviews were scheduled at an agreedupon time and venue on campus after each interviewee read and signed the irbapproved consent form the researcher conducted the interview and recorded it using a digital voice recorder the indepth interviews were semistructured giving the researcher the opportunity to ask followup questions wherever necessary some of the questions asked were what kind of healthcare is available to you and your family here at this university what is your opinion about the healthcare facilities that are available to you and your spousefamily here what are some barriers if at all that you encounter when you try to get adequate healthcare for yourself your spouse andor your family here at this university data analysis the transcripts of the focus groups and indepth interviews were analyzed keeping in mind the principles of constructivist grounded theory according to mills et al grounded theory is a methodology that seeks to construct theory about issues of importance in peoples lives through a process of data collection that is often described as inductive in nature in that the researcher has no preconceived ideas to prove or disprove rather issues of importance to participants emerge from the stories that they tell in fact in constructivist grounded theory the interactive process between the researcher and the research subjects brings out the reality in its temporal cultural and structural contexts this approach to data gathering was considered appropriate for this study because it would allow the researcher to interview participants without any preconceived notions and thereby offer participants an open discursive space within which to express themselves and cocreate meanings through their conversations with the researcher the main questions asked during the indepth interviews were informed by the viewpoints that participants articulated during the focus groups for instance the first question of the focus group asked participants to share their experiences while trying to get healthcare for their spouses or children at the university the ensuing discussions revealed a deep sense of dissatisfaction that students articulated and negative opinions about the university in order to provide students a discursive space to voice their feelings more openly in the indepth interview a question was included that asked their opinion about the healthcare facilities that are available to you and your spousefamily here at this university also during the focus groups while talking about their experiences trying to get healthcare for their families a number of participants mentioned the mental stress they underwent and how that in turn affected their studies in order to give students a fuller scope to talk about this a question was included in the indepth interviews which asked in what ways the health of your spouse andor family affect you as a student thus the questions of the indepth interview examine more intensely issues that came up in the focus groups and help students andor their spouses elaborate upon some of the viewpoints that were raised during the focus groups the audio files of the interviews were transcribed by the researcher and a research assistant and analyzed using the constructivist grounded theory approach the transcripts of the indepth interviews were closely read multiple times by both the research and his research assistant followed by open coding axial coding and selective coding the involvement of two coders in the transcription and coding stage ensured greater reliability and validity of the data during open coding the researcher went line by line through the transcripts noting down first impressions through code words jotted alongside the lines a total of 51 codes emerged from open coding among these codes were high cost of insurance limited income as students spouse not allowed to work as a dependent of an international student and dependence on personal funds in the axial coding phase similar codes arrived at during the open coding phase were grouped into 12 broader categories or axial codes for instance open codes such as use of home remedies dependence on young age to stay healthy bringing medicines from home were grouped under the category of ways of coping in the selective coding phase the axial codes were further reduced into three major themes during the different stages of open axial and selective coding the researcher conversed with some of the interviewees to evaluate the validity of our findings once the final themes were decided upon these were discussed with these interviewees to ascertain the validity of the themes these themes have been reported in the findings section trustworthiness and credibility in order to ascertain trustworthiness and credibility in the findings the researcher used data triangulation the transcripts of the focus groups as well as those of the interviews along with the memos kept after each interview and focus group were all read and reread multiple times and used together during the data analysis to ensure that the findings were trustworthy and credible results the results of the indepth interviews can be placed under three broad categories that correspond with the research questions that this study aimed to answer the barriers that married international students andor their spouses faced trying to access adequate healthcare the strategies they adopted to overcome the barriers and suggestions they offered to address the problems surrounding healthcare access this results section is therefore divided into three sections respectively the first section that talks about the barriers to healthcare is further subdivided into two parts the prohibitive cost of health insurance and the lack of understanding of the american healthcare system the third section that discusses interventions is also divided into three suggestions insurance with more options better dissemination of information and expanding services at the universitys student health center barriers to healthcare the primary barrier that prevented married international students from accessing adequate healthcare for their spouses andor families was the prohibitive cost of health insurance what compounded the problem were the complexities of the american healthcare system that students and their spousesnew to the usfound difficult to understand and navigate through the following sections elaborate on both these issues the prohibitive cost of health insurance the biggest barrier to healthcare that the focus groups and indepth interviews revealed was the prohibitive cost of health insurance majority of participants in the study reported that their spouses did not have health insurance simply because it was too expensive for them they reasoned that given the high cost of health insurance and their meager income it was financially more prudent to preserve the money they would spend on health insurance premiums every month and use it if and only if their spouses ever needed medical assistance students cited numerous scenarios where they had no leeway in terms of income with which they could afford health insurance for their spouse participant no 3 in focus group 1 for instance reported earning 772 a month as a quartertime graduate assistant out of this amount he said he paid 628 for his onebedroom apartment and 30 to 40 for gas for his car consequently he reported meeting his other expenses with money from his savings which left him no option but to leave his spouse out of his health insurance plan lack of understanding of the american healthcare system another barrier to accessing adequate healthcare was a lack of understanding among international students about the workings of the healthcare system in the us indepth interviewee no 6 for instance was caught unawares when his wife became pregnant right after his joining the university as a doctoral student from an african county since he had insurance for his wife he assumed his wife was covered but he discovered that she would not get insurance benefits until he had paid enough money through premiums into her account the following excerpt from his indepth interview reflects his frustration interviewee 6 the authorities need to do a lot of enlightening or orientation or educating of the incoming students so that they know how the system functions secondly the health insurance companies themselves also need to do a bit of educating because its like youre taken unawares because if i knew theyre not going to cover this then why do i end up spending 460 bucks and my account being in red i could have used that and said hey lets go by fate if anybody falls ill well try our luck because that makes more sense like thats fraud thats broadday fraud theyre taking money from me yet i cannot get anything from them researcher they should let you know right when you are starting off that okay youre being charged 460 a month but you will not be able to withdraw anything for 1 year interviewee 6 yeah researcher that needs to be told right at the getgo did they tell you that interviewee 6 no nobody tells you that interviewee no 4 also articulated the need for international students to be educated about how the medical system works in the us another barrier to healthcare is knowing how the medicares system in the united states works so sometimes we dont know how to respond you know how to check in how to check out how to pay the medical bill this is also a barrier since were not familiar with this medical system interviewee no 5 a graduate student from pakistan also voiced a need for educating incoming international students about how the medical and financial system work in the us to illustrate his point he mentioned an instance where he had to engage in a prolonged exchange with a laboratory that could not access his insurance information and was therefore forcing him to pay a certain amount after receiving numerous bills from the laboratorywhich also had reported his name to a collection agencyand making repeated phone calls to his insurance company he succeeded in resolving the issue the focus groups and interviews also revealed a dearth of information on the healthcare resources available in the offcampus community for the underinsured and the uninsured few participants for instance knew about a community health center that was there offcampus which served the uninsured and those living below the poverty line in the area for the past 25 years also out of all the interviews and focus groups that were conducted only one focus group participanta graduate student from indiareferred to a health insurance program that was there for uninsured residents of the state coping strategies besides taking the risk of not signing up for health insurance for their spouses international graduate students employed various unsafe strategies to encounter the barriers they faced in trying to get adequate healthcare for their families for couples without children where the spouse of the student did not have health insurance a common strategy was to bring medicines from their home countries with which they treated minor health problems in some extreme cases spouses without insurance simply tried out home remedies hoping a certain physical ailment will cure itself in time participant no 3 in focus group 1 for instance stated that for the past few months his wife had been suffering from sensitivity in her teeth but had been trying to cure the problem using the home remedy of brushing her teeth with turmeric powder and oil twice a daya strategy that had not brought her any relief the exorbitant cost of healthcare sometimes deterred even those with insurance from seeking medical help indepth interviewee no 5 for instance had the following narrative interviewee once my daughter was a little sick i was very worried as to what i should do that she was vomiting once or twice so i was thinking if i should go to the emergency or whether i should wait researcher because emergency room is more expensive interviewee yeah and if they admit you then your bill will cross 1000 or something so i contacted the nurse and she gave some tips and she was fine but there could be something which could get out of your control another strategy articulated during the focus groups was getting shortterm travelers insurance from ones home country participants also spoke of using money from their savingswhich they had accumulated while they were employed prior to their graduate studies for example participant no 2 from focus group 1a masters student from indiasaid he was employed for 20 h a week as a tutor on campus for which he got paid 12 an hour he supplemented his income by the savings he had put aside while working fulltime for 6 years before returning to graduate school since he was employed for 20 h a week he paid 1135 per year for his health insurance at the time of the focus group he intended to get a travelers insurance for his wife who was scheduled to come to the us the following month paying 4985 for his and his wifes insurance was beyond his means he said he however did not consider his case an anomaly since according to him several masters students in his department did not have funding from the department focus group participant no 6 a phd student from south korea who talked about coming from a poor workingclass family said he supplemented his assistantship salary with moneya very very small amountthat he brought from his home country incidentally participant no 6 was one of those individuals who said that his wife did not have insurance at the time of the focus group they had just had their first child although medicaid covered the childsince he was a us citizen by birthparticipant 6 had to apply for emergency medicaid for his wife in order to pay for the delivery he also applied for financial assistance from the hospital so that his portion of the hospital bill was subsidized in addition he reported engaging in intense financial juggling in order to make ends meet interviewee no 6 ive been able to do additional hours during the summer vs the usual 20 hours when school is in session and that gives me extra income and i save up huge because i know that hey ive got a family thats one secondly ive latched on to credit cards very much so you kind of revolve and what that does is it puts you back in a continuous cycle so what ive done is to be strategic in the sense that when i do summer jobs i use them to pay off my credit cards researcher and then the credit cards are free for you to use during the school year interviewee no 6 exactly so its kind of being strategic backandforth coping with intense financial pressure can take a toll on students as was revealed in particular during focus groups as one focus participant stated see we are here to study focus on research or whatever these things financial pressure really bother us a lot i dont see even a single day me not thinking about this aspect of life which is affecting me the following exchange between a chinese focus group participant and the researcher also revealed that struggling with myriad copying strategies against inadequate healthcare facilities made international students feel as though the university did not care enough to help them in their predicament participant no5 this university is known for its large majority of international graduate students researcher yes suggested interventions along with articulating the barriers they faced trying to access adequate healthcare for their spouses and families research participants in this project offered suggestions on how the university could fix the problem surrounding healthcare for the families of married international students their suggestions have been placed under three sections better communication of information insurance with more options and expanding services at the universitys student health center the following sections elaborate on each of these suggestions better communication of information one of the major barriers to healthcare which emerged in this study was the need for better communication of information to international students regarding the benefits that their health insurance can get them a clearer idea of the healthcare facilities that are available to them on and offcampus and an overall understanding of how the healthcare system works in the usa number of participants complained that coming from another country they had a hard time understanding the healthcare system in the us with its copayments deductibles and so on indepth interviewee no 6 for instance complained about the lack of education or clarity about what the insurance program can or cannot offer you blindly get involved in a routine into the health insurance program that doesnt cover anything for you but they collect money from you i mean it is so annoying in addition to the opinions expressed by the participants the need for more information also was revealed by the fact that few intervieweesonly three out of a total of 22seemed to be aware of an offcampus healthcare facility where the uninsured and the underinsured could seek medical assistance at a subsidized rate indepth interviewee no 3 also articulated the need for more information regarding urgent care since the university student health facility did not have a 247 emergency room one of the participants of the first focus group in fact suggested that the university ought to have consultants that international students could go to if they were faced with any major dilemma regarding healthcare as well as student life in general she said i was thinking maybe there can be some consultants whenever we have any questions we can go over to them and ask you have housing problems you have health issues you can go to someone and ask what shall i do this is new experience for us we dont have the time to find out how to call and how to file claim at least have someone who can help us deal with all these issues if you cannot help us directly financially insurance with more options one of the main suggestions that participants in this study offered was that the university should give more options to students when it comes to purchasing student health insurance by options participants referred to alternative insurance plans that students could opt for based on the amount of medical assistance they need as indepth interviewee no 1 said interviewee no 1 i think if they the university can figure out a better way to tell different group of people apart they can design a more reasonable insurance package for low risk group like us with acceptable insurance fee i think we are really happy to take that researcher so youre saying more segmentation in terms of interviewee no 1 kind of researcher so people who are less likely to fall sick can be offered a cheaper insurance not just one big broad service under whom everyone is brought is that what you are saying interviewee no1 yeah yeah you got it indepth interviewee no 2 also emphasized the need for the university to offer insurance plans that are customized to the students needs since most collegeaged students are in their 20s and 30s interviewee no 2 proposed that the university health insurance could opt not to cover certain diseases that usually do not affect younger populations but rather focus on health problems that are common among young people indepth interviewee no 5 suggested having two or three options to choose from he also favored the idea of the university using multiple vendors so that they could compete with each other and offer the best prices for students indepth interviewee no 3 said that the university should negotiate better with insurance companies to lower health insurance costs for students expanding services at the universitys student health center in spite of there being a womens clinic at the universitys student health center a number of participants in this study articulated the need for a womens health section at the student health center where pregnant women in particular could go for medical assistance some interviewees who had children also expressed a wish for a pediatric section where children of students could go for treatment in the following conversation for example indepth interviewee no 6 whose wife gave birth to two children after he became a graduate student articulated the need for a womans health section and a pediatric section at the student healthcare center interviewee no6 they need to have the facilities they need to recruit physicians they need to have a section that treats pregnant women they need to have a section for children because if my kids are not feeling well i cannot take them to the oncampus health center researcher i know interviewee no 6 if my wife is not feeling well i cannot take her there but im still paying money to them what sense does that make interviewee no 6 also expressed reservations in the following excerpt about the quality of services he received at the student health center interviewee no 6 most of the people there do not have expertise in their fields just a few of them do they treat you like when you go to a specialist they sit down and listen to you and see because it looks like they are under a clock to kick you out within a space of 10 minutes or 6 minutes researcher because there are people waiting outside interviewee no 6 yeah which doesnt make sense as is evidenced in the above categories under which the overall themes of the interviews and focus groups have been presented participants had lots of anecdotes by which they illustrated their struggle in accessing adequate healthcare for their spouses and children at the same time they also were vocal in articulating possible interventions and solutions by which the system could be changed for the better the implications of their viewpoints will be discussed in the next section discussion the main purpose of this project was to examine the barriers that married international students faced at this particular midwestern university while trying to access adequate healthcare for their families it was therefore considered best to begin with giving those affected to communicate firsthand the barriers they faced and then propose solutionsboth material as well as communicativethat would ameliorate the situation incidentally as the researcher was an international student at the same university he found the suggested health interventions most reasonable and implementableand certainly some of the best approaches one could take to address the problems the researched demographic was encountering through focus groups and indepth interviews the primary barrier that emerged was one of affordability the health insurance rates that were offered to spouses and children of international students were too high for students to affordwho at best were supported by their 20h graduate assistantship or at worst were entirely selffunded in other words the primary need of money which was found to be the foremost need among international students in the nafsa study conducted back in the 1980s continues to hound international students three decades later the financial instability and restrictions that de verthelyi discovered among spouses of international students at a large university in rural virginia back in the mid1990s also remained a concern among students and their spouses at the site of the current research in the midwest in addition to the material problem of affordability there also emerged an equally pressing problem of a lack of communication between international students and the university especially in explaining to international students a healthcare system thats new to them thus the problem of unfamiliarity with the american medical insurance system that vogel revealed among wives of japanese students in harvard university in the 1980s continued to be an unresolved issue as several of the interviewees and focus group participants in this study articulated a dire need for the university to better inform international students on how the healthcare system functions in the us as well as what facilities their insurance could or could not provide them participants in this study also suggested the need for more insurance optionswith the options being more affordable participants also articulated the need for the university to expand its services at the student healthcare centeradding in particular a childrens section and a womens health section that could assist pregnant women the persistence of some of the abovementioned problems over the decades raises some disturbing questions one wonders why the same problems affected international students at different universities in different parts of the country during different decades if international students indeed bring valuable skills into the us and contribute in particular to americas advancements in science technology and engineering disciplines how is it that the needs of this particular segment of the student population has gone unaddressed is there then a link between this lingering issue and the feeling expressed by a number of participants that the university is really not concerned about its international studentsin spite of publicizing and priding itself on its large international student population can that be said in general about the american academe too it needs to be emphasized that the focus groups and indepth interviews for this research project were being conducted two years after the affordable care act had been signed into law yet not a single research participant reported being benefited by it or talked about using it was that because the affordable care act in its early days wasnt available to international students families or were international students not aware about it the researcher of this project had called the affordable care act customer service while gathering data for this project and was told at that time that the act was available only to us citizens and green card holders currently however the healthcaregov website does list an i20 which is a certificate of eligibility for nonimmigrant student status and a foreign passport as documents one can use while applying for and enrolling in marketplace coverage the researcher once again had contacted the affordable care act customer service to clarify this listing he was informed that spouses and families of international students could now apply for health insurance through the marketplace as long as they had their i20s nevertheless it would depend on the individual application if one would be approved for coverage or not it is also noteworthy that none of the research participants revealed any knowledge of the special supplemental nutrition program for women infants and children which is administered by the food and nutrition service of the us department of agriculture to help women and children who live in poverty lead healthy and nutritious lives according to the wic webpage health care referrals is one of the services wic provides the results of this study substantiate the idea underlying the culturecentered approach to health communication that structural inequities go handinhand with communicative inequities through the narratives of the research participants we discovered that there is a gaping lacuna in communication between international students and the university in addition to the material need for affordable health insurance options for international students families the absence of a twoway communication channel or platform where international students could get their questions regarding healthcare for their accompanying families answered only exacerbated their sense of feeling lost in a new culture as research participants in this study revealed a new international student in the us needs to be informed about all the options available to her or him and would need the university she or he was enrolled in to help her or him understand and navigate through the health insurance system which is likely to be confusing to a foreigner the health insurance information at the university where this study was conducted does not discuss the affordable care act options on the webpage where it elaborates on student health insurance there is infact a condition that appears in bold fonts on the enrollment information page for international students that reads enrollment in student insurance is a condition of enrollment for international students and is mandatory sic the only cases were a student may get a waiver to buy student health insurance is when the students home government is providing a health insurance that is comparable to that of the university or when the student is sponsored 100 by a us organization such as fulbright or usaid and has insurance provided by them or when the student is in an approved exchange program or when she or he already has health insurance through a usbased employer at the site of this research project at the time when the data was being gathered there was no forum or entity on campus where international students could go for guidance as they negotiated an entirely new medical system in a foreign country a lack of empathy for the problems faced by married international students was reflected in the simple math that indicated that health insurance rates which the university offered spouses and children of international students were too high when compared with the assistantships that several graduate international students depended on for their livelihood this lack of concern was in congruence with martens and grants statement that universities typically tend to ignore the welfare of the spouses of international students as not being within their realm of responsibility the dearth of empathy also bolsters the claim that santiago et al made when they labeled graduate students lowwage earners within the structures of higher education institutes international graduate students who are more disadvantaged than domestic graduate students by the limitations of their immigration status which also restricts working options for their spouses are perhaps too lower down in the labor hierarchy to draw the attention of the university authorities especially with regards to matters related to their spouses the financial hardship of married international students also is a glaring example of how the structures of federal regulation can marginalize a minority group it must be remembered that much of this hardship is the result of federal laws that restrict the number of hours that international students can work during a week while school is in session to 20 h and which additionally prohibit the spouse of an f1visa holder from working altogether these regulations thus deprive married international students and their spouses of the agency to redress their own financial situation at the institutional level also there was no platform where international students could articulate their needs and seek a remedy while it is beyond the scope of any educational institution to modify federal laws providing better financial options to those already economicallydisadvantaged by federal rules could be a positive step toward building a positive relationship between the university and its international student population as one participant said by offering better healthcare facilities and health insurance options the university could convey a symbolic message to its current and prospective international students that it cares about their wellbeing and that of their immediate families another compelling aspect of the focus groups and interviews was the detailed suggestions that participants offered as solutions to their problem of accessing adequate healthcare for their families the practicality of these interventions demonstrates how if provided the discursive space to articulate their viewpoints marginalized sections of society can indeed produce viable answers to their own problems it is to be noted that each of the solutions proposed by the participantsfor instance the suggestion to educate incoming international students on how the healthcare and insurance systems work in the us or the suggestion to provide more health insurance options to studentsis most reasonable and implementable in fact listening to how financial problems jeopardized the overall mental wellbeing of international students and their families one might argue that there actually is a strong pragmatic reason why any academic institution should address this problem urgently this is especially true for international students whose children are unwell indepth interviewee no 6 whose wife became pregnant and whose daughter fell sick at the same time is such an example another such example is the focus group participant from south korea whose wife had no medical insurance yet found that she was pregnant from a practical standpoint a university would do itself a disservice if its international students and scholars were unable to put their best into or focus on their academic pursuits merely because they were too occupied by their financial woes in trying to obtain proper healthcare for their spouses and children this paper reveals a major problem that has been ongoing in the international student community across america over the decades but for the first time in addition to listening to the abiding problems we also get to hear the voices of international students and their spouses as they propose interventions to change the existing system as a former international student who studied at two different universities in two different parts of the us the researcher does not recall a single occasion where he was asked to fill out a survey or answer a questionnaire that examined the problems of his international student life in fact at numerous points during his graduate studies he felt there was an unspoken assumption in the academe that financial hardships were almost a rite of passage for those pursuing higher education in this country this research project therefore provided a muchneeded discursive space that foregrounded the rarelyheard voices of international studentsand especially their spousesand acknowledged their agency as they articulated ways in which the structural inequities of the healthcare system within the american academe can be redressed through practical steps as well as communicative means practical implications this study has implications not only for the particular site where the research was conducted but also for the american academia in general for the particular university where the project was conducted the suggestions offered by the research subjects provide concrete steps that can be taken to improve the healthcare that is available to families of international students there is also the need for the university to establish a twoway communication platform or forum specifically that caters to the needs of international students as they acclimatize to their new environmentwhich is essential for their academic success but beyond these practical steps there is a pressing need for the structures of american higher education to engage in a soulsearching that would answer why international students who contribute so much to universities across the nation feel unwelcomed in some cases and what measures can be taken to ensure that graduate students both international and domestic who typically contribute substantially to a universitys research output by assisting professors can be treated in a manner both in terms of remuneration as well as recognition where their status is better than that of a low wage earner limitations one of the limitations of this study is that the international students interviewed were all men accompanied by their wives who were their dependents no female married international student with a dependent husband was among the interviewees or among the focus group participants nor were there any queer married students or students with apparent disabilities therefore the viewpoints revealed in this study belong to heterosexual male married international graduate students and their spouses who are all relatively healthy the study also does not focus on how race or gender might influence the perceptions of the interviewees finally due to reasons of confidentiality focus group participants and interviewees were not asked if they were masters students or doctoral students therefore the study is unable to make a distinction between the viewpoints of masters students and doctoral students future studies could explore the unmet healthcare needs of lgbtq international students it will also be interesting to factor in race and examine the barriers that international students of color face trying to access adequate healthcare facilities at their universities another study could examine the challenges that international students with disabilities face getting sufficient healthcare support at their universities data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by purdue university irb the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

despite the vast numbers of international students in the us as well as their contribution to the economy their voices are rarely heard within the discursive spaces of the american academe this study takes a step toward filling that gap and seeks to open up a platform where married international graduate students at a large midwestern university could communicate in particular the barriers they faced while accessing healthcare facilities for their families using a culturecentered approach to health communication through focus groups and indepth interviews this study provides a discursive space where international students and spouses articulate vivid narratives of the problems they encountered while negotiating the american healthcare system revealing a basic issue of una ordability of students spousal health insurance accompanied by a dire need for better communication between international students and the university with there being a need for the latter to better explain to international students a healthcare system that is new to them as well as communicating with them with better clarity the available healthcare options for them and their spouses the participants also proposed interventions to redress the problems including the need for better dissemination of information regarding healthcare keywords culturecentered approach health interventions international students foreign students health communication indepth interview focus groups

background there has been renewed interest in epidemiology on how aspects related to the place in which people live may affect health outcomes placebased features are hypothesized to affect health over and above other individual characteristics through multiple pathways 1 2 3 4 5 6 7 studies on the association between neighborhood conditions and health have mostly characterized neighborhoods using measures derived from census databases 23 despite practical advantages the use of aggregate measures implies important limitations including decennial periodicity of data gathering changes in boundaries of units over time and the sensitivity of some measures to the dynamic process of migration and emigration in neighborhoods moreover they are only indirect proxies for specific neighborhood aspects that may be relevant to health outcomes the use of indirect indicators can hinder causal inferences regarding neighborhood effects on health in observational studies 28 a variety of other approaches are available to directly measure neighborhood attributes these include systematic social observation 9 the use of geographic information systems to create measures about resource availability and access 10 and administration of questionnaires to residents in order to obtain information on their perception of neighborhood conditions 8 each approach provides different and complementary information 8 measures of residents perceptions of neighborhood attributes can be examined in two ways on one hand they can be studied in relation to individuallevel health outcomes in individual level analyses a second approach involves building contextual variables through the aggregation of the responses of all residents of a given neighborhood the underlying assumption is that the process of aggregating individual perceptions results in a more valid measure of objective attributes 8 analytical approaches involving the use of threelevel multilevel analyses have been used to create these measures 1112 physical attributes of places in which people live and theirs perception about them are important health determinants beyond socioeconomic influence 13 the perception of place in which people dwell may impact on individual health and may be a more telling indicator for individual health than objective neighborhood characteristics studies that combine residents perceived neighborhoods aspects and census measures have been tending to find stronger relationships between environment and outcomes than those studies that rely only on aggregate data 14 studies have suggested indeed that objective and subjective measures of neighborhood may contribute independently to health and wellbeing 15 perceptions of neighborhood problems may be influenced by individuallevel characteristics of respondents as well as by the objective features of the neighborhoods in which individuals reside 1617 neighborhood socioeconomic disadvantage broadly reflects aggregate features of households furthermore the clustering of householdslevel deprivation in neighborhoods appears to generate local contexts that induce healthrelated processes 18 diezroux mair 2 added that low income participants may live closer to areas with adverse environments than high income individuals even living at the same neighborhood 2 neighborhoods with higher levels of problems can be less attractive to people with higher income and reach lower prices in the real estate market effects of land use with industrialization have had highly uneven effects at local levels as households experiencing a diverse range of disadvantages are increasingly clustered in poor neighborhoods 19 notably in brazil a large process of rural exodus with overcrowding in metropolitan regions encouraged poverty concentration in some areas with worst life conditions considered more vulnerable in periphery areas devoid of amenities services and even social spaces and designed to poorer people 20 several studies have examined factors related to neighborhood perceptions in highincome countries 1217 factors found to be related to neighborhood perceptions have included neighborhood characteristics as well as individuallevel characteristics such as education and occupational status age and time spent in the neighborhood a 1217 studies in different populations have reported association among perceived neighborhood aspects and distinct health outcomes as smoke 21 selfrated health 1722 cardiovascular disease 8 emotional health and others 22 however few studies have examined the predictors or measurement properties of neighborhood perceptions in medium and low income countries which may be different from those high income countries due the contextual socioeconomic and cultural differences 23 this paper aimed to assess the ecometric and psychometric properties of a scale assessing the perception of neighborhood problems by adults living in florianopolis sc a city in southern brazil with half a million inhabitants methods sampling procedures data were derived from the baseline examination of a populationbased cohort study called epifloripa carried out in florianopolis southern brazil from september 2009 to january 2010 the objective of the epifloripa study was investigating health and life conditions of the adult population of the city the study was conducted for teachers and postgraduate students from the federal university of santa catarina from different departments furthermore researches of other institutions collaborate in the design and analysis of epifloripa study the second wave of epifloripa study began in 2011 florianopolis is the capital of the state of santa catarina with a population of 421240 inhabitants 24 and presents a gini index of 040 lower that the country average 24 however it still has striking social inequalities and around 14 of population lives in poor housing conditions 25 we selected 60 of the 420 urban residential census tracts of the city all 420 urban census tracts of the city were ranked according to the average monthly income of the head of the family 26 classified into income deciles six tracts were randomly selected in each income decile all selected census tracts were visited by the fieldwork team and all occupied houses were enumerated the enumeration identified some changes in the sizes of the census tracts to reduce the variability in the number of households in each census tract some of them were split and others aggregated taking into considering their income decile and geographic localization this process resulted in sixtythree census tracts with 16755 eligible households within each census tract we systematically selected 18 occupied households in each household all adults were invited to take part in the survey eligibility and exclusion criteria all adults aged 20 to 59 years who were residents in the selected houses were eligible to participate exclusion criteria included amputees bedridden individuals individuals who could not remain in the proper position for the required measurements and those who were unable to answer questionnaire due to physical or cognitive impairments anthropometric and blood pressure measurements were not obtained from pregnant women women who had delivered a baby within the past 6 months were excluded we attempted to find all eligible adults in their home at least four times with at least one visit on weekends and another in the evening cases in which the interviewer could not locate the interviewee or there was a refusal to participate were considered losses data collection before initiating data collection the questionnaire was pilot tested on 35 individuals and the procedures were pilot tested on 100 individuals who were not study participants home visits included the administration of a facetoface questionnaire two blood pressure measurements and anthropometric measurements such as weight and height all interviewers were trained prior to field work outcome participant reports of perceived neighborhood problems were the dependent variables neighborhood perceptions were evaluated based on responses to 16 items referring to garbage uneven pavements unpleasant smells air water or ground pollution lack of safe place to children play traffic speed urban transport vandalism burglaries assaults murders drug use safety walking after dark bad reputation and police problems these items were adapted from a questionnaire developed by ellaway et al 27 for each item the response options were none some or many problems in the neighborhood for analysis those options were codded as zero one or two respectively grouplevel covariates we used the tertiles of the household head of the family average monthly per capita income from the 2000 brazilian census for each of the 63 census tracts individuallevel covariates the individual covariates included sex age educational attainment total of earnings in the last month by the household residents divided by the number of residents per capita income in reais raceselfreported skin color 24 length of time living in the neighborhood and occupational status which was classified according the british registrar generals social class 28 reliability was assessed by administering a short version of the questionnaire to 15 of the whole sample using a telephone interview reliability is defined as the extent to which the questionnaire produces the same results on repeated trials the measure can be used to assess the stability or consistency of scores over time or across raters 29 kappa statistics and the intraclass correlation coefficient were calculated to assess reliability and the values ranged from 06 to 09 statistical analysis in order to group perceived neighborhood items in scales we performed a principal factor analysis of all neighborhood questionnaire items after polychoric transformation 30 using orthogonal rotation the scree test factor loadings scale internal consistency and theoretical considerations were applied to define the number of factors to be extracted as well as the items comprising each scale the cronbachs alpha was calculated to measure the internal consistency of the scales 31 sample size adequacy for factor analysis was evaluated using the kaisermeyerolkin test 32 the values of kmo test ranged from 081 to 094 for vandalism and assaults respectively and the global value was 088 furthermore assessing the measurement properties of ecological settings moves beyond an assessment of the psychometric properties to what has been termed ecometrics 16 ecometrics is an extension of the two levels implicit in traditional psychometric assessments because it introduces a third level of neighborhoods it allows the quantification not only of how consistently individuals respond to the different component items of a scale but also the extent to which residents of the same neighborhood rate their neighborhood similarly 16 the ecometric properties of the neighborhood scales were assessed using threelevel multilevel models 11 level 1 corresponds to item responses within individuals level 2 corresponds to persons nested within neighborhoods and finally level 3 corresponds to neighborhoods through those analyses variance components were estimated for each level withinperson withinneighborhood and betweenneighborhood for levels 1 2 and 3 respectively using this estimates we calculated the intraclass correlation coefficient and the reliability of the neighborhoodlevel measure the icc quantifies the percentage of variability in the scale score that lies between neighborhoods 33 the icc ranges from 0 to 1 with a higher value indicating greater agreement between respondents within a neighborhood the neighborhood level reliability of the neighborhood score 1133 is a function of the icc as well as the number of participants in each neighborhood it is calculated as the ratio of the true score variance to the observed score variance in the sample neighborhood mean with values ranging from 0 to 1 the reliability will be high when 1 the neighborhood means vary substantially across neighborhoods or 2 the sample size per neighborhood is large furthermore this measure also increases when the number of scale items raises the threelevel multilevel analysis allowed the estimation of bayesian estimates 11 crude scores were tested in relation to individual and census tract level variables in order to evaluate the convergent validity related to spread which scales were associated with other neighborhood characteristics in the expected direction were investigated associations among perceived neighborhood scales and familiar per capita income from the brazilian census 24 we fitted three different models for each neighborhood scale the first model included demographic variables the second model added individuallevel socioeconomic characteristics and the third model added census tract income all variables were kept in the model the icc was calculated for each model the software stata version 120 was used to perform these analyses univariate and bivariate analyses were performed taking the complex sample into account considering unequal probability to participate of data gathering of residents from different census tract all multilevel models were also weighted ethical issues the research project approved by the ethics committee of research in human subjects of the federal university of santa catarinanumber 35108 informed consent was obtained from all participants results the response rate was 853 participants were distributed in 63 census tract with a range of 10 to 40 persons per tract and an average of 273 respondents per tract over half of the sample was female the mean age of the sample was 381 yr and almost 90 reported being white the mean length of time living in the neighborhood was 134 years residents perceptions of neighborhood problems were grouped in two dimensions after principal factor analysis neighborhood physical problems and neighborhood social disorder with internal consistency of 067 and 081 respectively the variables with higher factorial loadings on neighborhood physical problems were garbage uneven pavements unpleasant smells and air water or ground pollution the variables with higher loadings on the social disorder factor were burglaries assaults drug use vandalism and murders or kidnappings these two factors explained 79 of the item variance the correlation between two neighborhood scales was 049 the neighborhood iccs observed for the scales were 028 and 027 for physical problems and social disorder respectively corresponding reliabilities were 095 and 096 in bivariate analyses individuals aged 50 years or over perceived fewer neighborhood physical problems than younger individuals those who had lived in the neighborhood more than five years reported higher neighborhood social disorder individuallevel socioeconomic characteristics were not significantly associated with the scales however there was a pattern by which individuals in the higher tertiles of family and neighborhood income reported lower scores than those in the bottom tertile conversely higher education tended to be associated with higher scores after adjustment an inverse association between age and neighborhood problems scales remained people living longer in the neighborhoods had higher scores for neighborhood social disorder problems whereas those with lower educational attainment reported fewer problems residents in higher income neighborhoods reported lower rates for neighborhood problems the icc remained stable even after all adjustments discussion this paper investigated the measurement properties of scales utilized to measure neighborhood problems in an urban area in brazil we also examined whether neighborhood problems were associated with selected individual and census tract level characteristics two neighborhood problems scales were identified from the 16 items one measuring physical characteristics and the other measuring social characteristics the internal consistency of the scales was high the ecometric properties of the scales measured by icc and reliability were good in the order of 024 to 028 for icc and 094 to 096 for reliability higher values on the scales representing higher level of problems in the physical and social domains were associated with younger age more length of time residing in the neighborhood and lower census tract income level the ecometric and psychometric properties of the scales were similar to those found in other studies using data from three in three united states sites mujahid et al 12 reported iccs ranging 005 to 051 for activities with neighbors and aesthetic quality respectively friche et al 24 in belo horizonte brazil tested ten scales and reported iccs ranging from 002 to 033 for social cohesion and walking environment respectively friche et al 23 investigated physical and social disorder scales similar to ours and reported iccs of 014 and 013 for physical and social disorder respectively the icc quantifies the percentage of variability in the scale that lies between neighborhoods high value of icc indicates greater agreement between respondents within a neighborhood 12 the values of reliability observed in the epifloripa study were high and similar to those found in a southeastern brazilian metropolis 23 these results indicate that the mean of scores are good estimators of the true neighborhood scores for each scale 12 corsi et al 34 analyzing ecometric properties of responses to questionnaire items from 2360 individuals residing in communities of 5 countries of the environmental profile of a communitys health study found reliabilities ranged from 081 for community social cohesion in urban communities to 096 for knowledge of the health effects of smoking in a rural communities the sixteen collected items on perceived neighborhood problems were grouped in two scales reflecting social and physical dimensions similar clustering of neighborhood measures has also been reported by others 2735 the neighborhood physical problems scales aspects was primarily linked to environmental problems such as garbage uneven pavements unpleasant smells and air on the other hand aspects connected with social problems such burglaries assaults drug use vandalism and murders loaded on a separate social disorder scale neighborhood physical problems and social disorder scales were moderately correlated suggesting that they may measure distinct although interrelated constructs 1617 neighborhood problems would be expected to be greater in residential areas with more social problems for example concern about issues such as litter and walking around after dark may be more severe in places in which antisocial behavior is not proscribed 14 the convergent validity of the scale attested for their relation with other variables in expected direction was good there is some evidence linking individual characteristics and perceived neighborhood problems 1217 in epifloripa study people aged 50 years and over perceived fewer problems in their neighborhood when compared with youngest similarly in a study of canadian adults pampalon et al 36 observed that people aged 45 years and over perceived fewer neighborhood social and environmental problems than the younger persons 36 the length of residence in the neighborhood was associated with higher scores for neighborhood social disorder ellaway et al 27 found that length of residence and neighborhood stability were found to be significant in two ways longer residence is associated up to a point with a stronger sense of neighboring and longer intended residence is itself a key element of attraction to neighborhood 27 people living longer in the same neighborhood may have a sense of the changes that have occurred in their neighborhood over time and perceive more violence problems in their neighborhoods 37 as expected people living in lower income areas reported more problems than those living in higher income areas for a number of reasons that have to do with inequities in power resource distributions and access to opportunities socially disadvantaged areas are likely to face adverse physical and social environments however contrary to expectation we found that individuallevel income was only weakly associated with neighborhood problems people in the higher income tertile presenting slightly lower scores of problems in neighborhood for educational attainment the association was the opposite of expectation with lower scores for groups with lower educational attainment years however associations with individual level ses were generally weak and often not statistically significant friche et al 23 noted similar patterns in the association of neighborhood scales with socioeconomic indicators they 23 pointed out the contrasts between poor areas adjacent to rich areas typically observed in brazilian urban centers as a possible explanations for the weak associations observed this may influence the individual responses because regardless of socioeconomic level people may share some similar environments and services available for a broader area resulting in similar perceptions across economically diverse adjacent neighborhoods 23 like other studies 1223 our results also suggest that there is variation in responses within neighborhoods part of this may be due to the arbitrary geographic definition of neighborhoods that we used although clearly census tracts capture some spatial heterogeneity there is likely to be substantial spatial heterogeneity which is not captured by census tracts 12 brazilian census tracts were defined to be the smallest territorial unit that can be reasonably covered in fieldwork each census tract has around 300 households 26 additional sources of variability within neighborhoods may be attributed to subjectivity inherent to perceptions and the error in measurement the occurrence of withinneighborhood differences suggests that it may be beneficial to average over neighborhood respondents or raters in estimating neighborhood characteristics 12 sample size in multilevel analyses has been an ongoing area of work the number of respondents in each cluster of epifloripa study ranged 10 to 40 only one of 63 census tract evaluated had only 10 observations the average number of individuals per grouplevel unit was 273 mujahid et al 12 reported that 2530 participants per cluster often maximizes reliability 33 mass e hoss 38 performed a serial of simulations with different numbers of groups and individuals in each group and observed nonsignificant bias for most regression and variance components under conditions similar to those observed in the epifloripa study however they did report that he standard errors of the secondlevel variance can be underestimated when the number of groups is substantially lower than 100 4 there is an ongoing debate on the nature of variables involved in neighborhood analyses cummins et al 4 argue that the distinction we often make between composition and context is somewhat artificial this can acquire special relevance when it comes to residents perceptions about their own neighborhood because an individuallevel variable is used to capture neighborhoodlevel realities however disaggregated individual and group sources of variability can be useful the fact that variance in reported can be decomposed into between area and within area variability indicates that these perceptions are at least in part capturing truly contextual features 38 conclusions the findings of this study showed acceptable ecometric properties of the proposal scales and documented associations of perceptions with individual and contextual socioeconomic characteristics those scales have been applied in analysis of epifloripa study against other outcomes ie selfrated health showing important association even after adjustment for other socioeconomic demographic health related behaviors and health status variables place specific characteristics related to broader geographic and social contexts such as cities or countries may influence the relationship between perceived neighborhood problems and objective socioeconomic measures at both the individual and census tract level future works can apply these scales to examine how places influence health abbreviations 95 ci 95 confidence intervals icc intraneighborhood correlation kmo kaisermeyerolkin or odds ratio competing interests

background physical attributes of the places in which people live as well as their perceptions of them may be important health determinants the perception of place in which people dwell may impact on individual health and may be a more telling indicator for individual health than objective neighborhood characteristics this paper aims to evaluate psychometric and ecometric properties of a scale on the perceptions of neighborhood problems in adults from florianopolis southern brazil methods individual census tract level per capita monthly familiar income and neighborhood problems perception physical and social disorders variables were investigated multilevel models items nested within persons persons nested within neighborhoods were run to assess ecometric properties of variables assessing neighborhood problems results the response rate was 853 1720 adults participants were distributed in 63 census tracts two scales were identified using 16 items physical problems and social disorder the ecometric properties of the scales satisfactory 024 to 028 for the intraclass correlation and 094 to 096 for reliability higher values on the scales of problems in the physical and social domains were associated with younger age more length of time residing in the same neighborhood and lower census tract income levelthe findings support the usefulness of these scales to measure physical and social disorder problems in neighborhoods

introduction sustainability needs to be ensured in the population for its harmonious life to contribute to this sustainability the sustainable development goals were proposed in 2015 which address the economic environmental and social aspects of society sdg 3 aims to ensure a healthy life and promote wellbeing for all at all ages specifically target 34 commits to reducing by 2030 by onethird premature mortality from noncommunicable diseases through prevention and treatment and promoting mental health and wellbeing in 2015 mental health was included as one of the main development objectives in the search for greater sustainability due to the fact that mental problems are affected by social determinants intertwined with the concern perceptions and consequences of armed conflicts for this reason all events that generate alterations in mental health will end up going against the sustainability of society for this reason all events such as witnessing a war conflict can generate alterations in mental health that will end up going against the sustainability of society since it could even cause psychiatric disorders covid19 has already generated a negative impact on the mental health of the population more specifically as depression anxiety and stress so any situation can worsen the mental health of the population just talking about a world war reminds us that there are weapons of mass destruction that are so powerful that they could leave their mark on the environment soil air and others for many centuries or even millennia similarly during the last century the world experienced the second world war when hitler ordered the nazi invasion of poland sustainability is a crucial concept that requires meeting present needs while safeguarding the capacity of future generations to meet their own needs its a comprehensive approach that takes into account the environmental social and economic aspects of development the united nations established sustainable development goal 3 which aims to promote healthy lives and wellbeing for all at all ages with a particular focus on mental health mental health plays a pivotal role in overall wellbeing contributing to sustainable development in various ways optimal mental health is fundamental to individual wellbeing enabling people to enjoy a fulfilling life and contributing to better health and quality of life moreover mental health has a significant impact on productivity and the economy as mental health issues can negatively affect participation in society and work resulting in decreased economic performance addressing mental health is crucial to promote social justice by ensuring equal access to health services and creating a more inclusive society lastly promoting mental health and preventing mental disorders can reduce the burden of disease thus leading to a healthier and more sustainable society in this context the concern of the population reached a critical level in february 2022 when russia invaded ukrainian territory to start a war with this nation the united states and europe gave their support to ukraine as did china to its russian ally fortunately after a few months the possible military conflict stabilized and did not escalate however at the time of the events it was thought that the worst could happen it is important to mention that at that time the world was going at the same time of the covid19 pandemic this already had some repercussions on the mental scale and there were multiple multicenter reports of large populations that show that in this pandemic the mental sphere of the most affected populations deteriorated this also happened in latin america which was the most affected in terms of per capita mortality and other countries that due to their precarious health systems suffered greatly and have still not fully recovered this situation could have been worst but the high acceptance of covid19 vaccination in latin america helped to partially alleviate the fear caused by the pandemic therefore as we are coming out of a pandemic and given the scarcity of research on the mental consequences in individuals from countries that were not directly involved in a war like the current one it is important to analyze how the stress anxiety and depression at this specific moment in recent history in latin america knowing that although a pandemic was important in the incidence of mental health having the possibility of a third world war in 2022 was a very important breaking point to have greater damage to the already broken mental health therefore the hypothesis established that there was a difference between three of the mental pathologies most commonly affected according to the perception that a new largescale war would be generated the objective of this study was to determine whether there is an association between anxiety depression and severe stress according to fear of a possible third world war in the context of the russiaukraine conflict in 13 countries of latin america materials and methods study design and sample crosssectional analytical research was conducted due to the suddenness of the conflict it was necessary to use this design by applying a single survey during the initial weeks of the russiaukraine conflict the survey lasted from march 5 to april 30 2022 that is from the second to the ninth week since the war started this was conducted in the countries of colombia paraguay peru bolivia ecuador mexico panama brazil and others in each of these countries most respondents were young urban population with technical or university studies which is the most accessible population through virtuality and occupies a significant percentage of the population in each of the latin american countries in the first phase of the research the validation of the instrument measuring the perception of fear or worry about an imminent world war was carried out a nonprobabilistic sampling was carried out since it was never intended to extrapolate the results to the entire population but it was desired to have enough respondents to obtain statistical associations due to this the statistical power of the main crosstabs was calculated being adequate the power for the crosstabs of the variable perception of fear or worry about an imminent world war according to anxiety depression and stress using this analysis it was possible to be certain that the main crosstabs had the necessary number of respondents to be able to trust the crosstabs and statistical results all based on excellent statistical power we included those who variables and instruments the dependent variables were three which were evaluated using the dass21 test the survey asks about what happened in the last week through seven questions for the measurement of each one all had four possible answers never a little quite a lot or a lot to obtain the results the sum of the corresponding questions for each outcome was made and according to the score five possible results were obtained normal values as well as probabilities of having the pathology in low moderate severe or very severe ranges the analytical statistics were dichotomized into severe and nonsevere alpha dass21 was calculated at 097 for the measurement of the main independent variable the test measuring the perception of fear or concern about an imminent world war was validated in the first phase of the research with the response of 1684 latin american residents during the russiaukraine conflict the validation process included obtaining preliminary analysis exploratory factor analysis and confirmatory analysis as well as cronbachs alpha measurement it should be noted that all the values obtained in the validation of the test were satisfactory therefore the prior validation process ensured that the instrument that measured fear in the face of a possible third world war was understandable and adapted to the reality of the respondents for the analytical statistics we categorized according to the score obtained from the total sum being considered as those who were afraid of world war iii those who were in the upper tercile of the total sum of the scores being compared versus those who were in the middle plus the lower tercile our research also obtained the value of cronbachs alpha being 092 we also considered the variables of sex age level of education country of residence perception of fear depression and stress related to the country of residence ethical issues the project was initiated days before the confirmation of the war conflict and was urgently submitted to the ethics committee to which the importance of an expedited review was explained the committee gave its approval especially because the surveys would be anonymous there would be no contact with the respondents the right to respond partially or totally to the survey would be respected the objective and other characteristics of the research would be mentioned in the initial part as well as not addressing vulnerable populations management and analysis of data once approval was obtained the survey was carried out for which two platforms were generated in google forms which were available during the entire period previously mentioned after the survey was completed the information was debugged and reviewed according to the selection criteria all this was done in a microsoft excel spreadsheet the information was then transferred to the stata program where the statistical analysis was performed the frequencies and percentages of the categorical variables were obtained this is where table 1 was generated with the percentage responses for each question of the fear test for the analysis of the quantitative variables their normality was first evaluated with the shapiro wilk statistical test and when it was determined that they had a nonnormal behavior they were described with the median and interquartile ranges then we went on to the construction of each of the bivariate and multivariate cross tables where generalized linear models were used to obtain the crude prevalence ratios adjusted prevalence ratios 95 confidence intervals and value of ps in addition epidemiological criteria were considered when entering all the adjustment variables even if they were not statistically significant as in the case of educational level especially due to the knowledge that this variable is important in the population evaluated through previous research in the final model 005 was considered as the cutoff point for statistical significance results of the 2626 respondents 611 were female the median age was 23 years and 897 were college graduates the main fear was that weapons of mass destruction would be used followed by that biological weapons would be used or atomic bombs in the crossover of severe or very severe anxiety according to fear of a possible world war a strong association was found furthermore there was more anxiety in ecuador but the level of anxiety was lower the older the person was and among men adjusted for educational level crude prevalence ratios adjusted prevalence ratios 95 confidence intervals and value of ps were obtained with generalized linear models bolivia and ecuador but the level of depression was lower the older the age and among 3 crude prevalence ratios adjusted prevalence ratios 95 confidence intervals and value of ps were obtained with generalized linear models variable taken as quantitative median is shown in the descriptive part likewise a strong association was found between severe or very severe stress and fear of a possible world war in addition there was more stress in colombia paraguay and ecuador and lower level of stress at older age and among men adjusted for educational level crude prevalence ratios adjusted prevalence ratios 95 confidence intervals and value of ps were obtained with generalized linear models variable taken as quantitative median is shown in the descriptive part discussion the association between the perceived fear of the possible outbreak of a world war and the anxiety depression and stress in severe or very severe degrees is confirmed as well as in previous conflicts it has also been shown that mental health is greatly affected there is a greater probability of mental health disorders in the displaced population as they have a greater need for mental health care services in territories affected by conflict a study of vietnam war veterans showed that the prevalence of posttraumatic stress disorder was 54 that of depression was 83 and 54 of veterans had suicidal thoughts similarly gulf war veterans developed posttraumatic stress disorder depression and multiple chronic illnesses another study of british personnel who participated in the iraq and afghanistan conflicts showed that 62 had probable posttraumatic stress disorder and 219 had common mental disorders also in the armed conflict in colombia the affected population developed emotional distress depressive symptoms anxiety and stress as can be observed most of the researchers inquire about those directly affected but there are few that evaluate this in the general population which is necessary especially since we are still in the context of the pandemic as a secondary result it is reported that the levels of anxiety depression or severe stress were important in some countries especially in the case of anxiety reaching levels between 12 and16 in most of them it is important to emphasize that these countries were severely affected by covid19 triggering damage to mental health for example one study revealed that in latin america more mental health symptoms such as posttraumatic stress disorder anxiety and depression were reported to be related to covid19 another study showed that latin america had a prevalence rate of depression and anxiety of 32 also a metaanalysis showed that the prevalence of anxiety and depression was 35 therefore it is important that each country measures the affectation of its population in mental health issues since each area had a different affectation than elsewhere and this could be accentuated in some specific subpopulations the population with the highest frequency of the three pathologies was the female population this has been demonstrated in a study from the university of maryland where they found the prevalence of depressive and anxiety symptoms in latin american and caribbean countries in which it was shown that the female gender and nonbinary gender people had more anxious and depressive symptoms compared with men during the covid19 pandemic in addition in european countries there is also evidence that women have low emotional stability which could be a reason for them to experience more symptoms of neuroticism although no clear explanation has been found for this it may be due to ovarian hormonal variations and the decrease in estrogen levels in women which is why they are more prone to present these types of disorders this is a clear example of a subpopulation that is more affected than another which should serve for the authorities to look for this in a more individualized way which will then serve to generate specific programs for the improvement of mental health finally these three pathologies occurred to a lesser extent among those who were older as demonstrated in different studies where it is observed that the young population is the one that presents stress anxiety and depression more frequently this is since it is the population with more time exposed to technology and information from social networks that trigger the presence of greater concern for their future in relation to the consequences in the economic and environmental sphere that these problems can generate this should be corroborated and we should see what are the other causes that generate that the youngest are the most affected by these stimuli of war and the possible concern for what is generated by it it is recognized that there is a limitation in terms of 100 extrapolation of the results obtained in this study due to the specific context of the russiaukraine war and the possible mental health disturbances associated with this conflict it is important to emphasize that the respondents from the 13 selected countries were not chosen randomly but rather based on the possibility of accessing the target population and on the connections and prior knowledge of the researchers in those countries although an effort was made to ensure the representativeness of the sample to the extent possible it is recognized that this may present certain limitations although there is limited evidence that mental health affects the sdg 3 the present study highlights this relationship as it is a dynamic aspect since the negative impact that had been generated by covid19 is continued by all the effect generated by the concerns related to the escalation of the war worldwide efforts to achieve the sustainable development goals are multidimensional because the contribution of this study is to show the importance of mental health in sustainability even beyond just sdg 3 we had the limitation of not being able to reach the older or rural population mainly due to the type of design whereby conducting a virtual survey we had more reach to the populations that have more use of technology and that are in cities with greater coverage of telephone and communication networks in addition our results cannot evaluate causality so it is not possible to know whether it is the fear of a third world war that generates an increase in pathologies of the mental sphere or vice versa in addition by relying on surveys we had the bias of reaching only the accessible population that wanted to answer the surveys however despite all these limitations we had access to more than two thousand people in latin american in the end of the pandemic which can generate a first report of this population which was so hard hit by the pandemic where peru brazil and argentina were three of the countries with the highest mortality globally this generates more hypotheses and supports further research on mental health issues conclusion based on the above findings it is concluded that a strong association was found between fear of a possible world war and having severe or very severe levels of anxiety depression or stress in the latin american population surveyed during the first weeks of the russiaukraine conflict it is important to consider that sustainability can be achieved to the extent that the sdgs can be met in the case of sdg 3 and specifically in target 34 a great deal of effort will be required from governments since as a war is ongoing mental health was negatively affected and if we add the covid19 pandemic the population will continue to be affected with all the social and economic impact that this implies it is important to keep in mind that this exploratory study represents a first approach to the association between severe anxiety depression and stress in the latin american population in the context of the aforementioned conflict in order to obtain more solid and generalizable conclusions future research will be necessary to include a more representative and random sample of the latin american region taking into consideration the diversity of contexts and sociopolitical situations data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by the committee gave its approval the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not 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sustainability may be at risk in a population that has altered health according to sustainable development goal 3 sdg 3 health and wellbeing the ongoing conflict between russia and ukraine could jeopardize sdg 3 specifically the mental health of the population the present study sought to determine the association between severe anxiety depression and stress in population of 13 latin american countries according to fear about the war conflict it was a crosssectional analytical and multicenter study anxiety depression and stress were measured with the dass21 test cronbachs alpha 097 and fear due to an armed crisis with a questionnaire already validated in latin america cronbachs alpha 092 which was also adjusted for sex age education level and country of residence descriptive and analytical statistics were obtained of the 2626 respondents the main fear was that weapons of mass destruction would be used in the multivariate models strong associations were found between fear of a possible worldscale armed conflict and having severe or very severe levels of anxiety apr 197 95 ci 164236 value of p 0001 depression apr 191 95 ci 154236 value of p 0001 or stress apr 205 95 ci 163257 value of p 0001 sustainability linked to sdg 3 specifically mental health is affected by this type of significant events given the possible global war crisis that could trigger major events even more so if added to the deterioration already experienced by covid19 in the latin american region insecurity and constant political uncertainty

introduction in order to investigate the hypothesis that people tend to conceive of social networks in local and spatial terms martin used random graphs to analyze the structure of a unique set of social networks these three networks are social networks of alternative personalities described by a patient patricia undergoing therapy for dissociative identity disorder whose drawings of these networks are reproduced in david et al one of the most striking findings in martin is the presence in one of these networks of a large hollow ring a cycle with no shortcuts which is much larger than those expected under the random graph models considered as discussed in stivala and recapitulated below this hollow ring is in fact a geodesic cycle in graph theory terms in martin the random graph null model used was the 𝑑𝑘series family of graph distributions and only the distribution of the largest geodesic cycle lengths is considered stivala extends this work by using exponential random graph models as well as the 𝑑𝑘series random graphs and also considering the geodesic cycle length distributions in addition to the maximum geodesic cycle lengths that work also examined a selection of other publicly available social networks as well as the original patricia networks finding that of the networks examined only the patricia networks seem to have geodesic cycle lengths that are not reproduced by random graph models commentary on stivala mostly concerned the mis interpretation of ergm parameters and the trend in the social networks field to be moving towards a monoculture of using parametric models and in particular ergms for everything what has not yet been addressed is to test the hypothesis suggested in stivala that fictional character networks for an overview and specifically those with only a single author might have anomalous geodesic cycle length distributions like the patricia networks the primary purpose of this work is to test this hypothesis by examining how well the geodesic cycle length distributions in some fictional character networks mostly from works by a single author can be reproduced by random graph models specifically the 𝑑𝑘series random graphs and in some cases exponential random graph models further it was implicitly assumed in stivala that the method used there for counting geodesic cycles was exact in fact however that method is only an approximation and so a second purpose of this work is to reproduce all of the results in stivala and compare with a method that counts geodesic cycles exactly geodesic cycles in this and the following sections only undirected graphs are considered as discussed in stivala the structure that martin describes as a hollow ring a cycle with no shortcuts so that the shortest path between any two nodes in the cycle is along the cycle itself is known in graph theory as a geodesic cycle another way of putting this is that a geodesic cycle is a cycle such that for any two vertices on the cycle the distance between them in the cycle is equal to their distance in the graph as mitchell writes of the proliferation of concepts and terms in social network analysis it is a terminological jungle in which any newcomer may plant a tree as quoted in mitchell and as noted in stivala a geodesic cycle has also been termed an isometric cycle and an atomic cycle adding yet another tree to the terminological jungle an isometric cycle has also been termed a short cycle unlike geodesic cycle chordless cycle is a wellknown standard term in graph theory although there are conflicting conventions as to whether or not cycles of length three are included in the definition a chord is an edge connecting two otherwise nonadjacent nodes in a cycle and a chordless cycle is a cycle that has no chords a chordless cycle is also known as an induced cycle or sometimes a hole for chordless cycles of length at least four every geodesic cycle is chordless but not every chordless cycle is geodesic an illustrated example of these definitions is given in stivala in stivala the findlargeatomiccycle algorithm was used to count geodesic cycles however despite the implicit assumption in that work that this algorithm enumerates geodesic cycles in fact this is not guaranteed the proof of correctness in gashler and martinez proves that any cycle it returns is geodesic and that it will find at least one of the specified minimum length if it exists however despite being described as iterating over all the atomic cycles in the graph and that atomic cycles in the graph are enumerated the proof does not show that all atomic cycles are enumerated and in fact it is not guaranteed to do so hence it does not exactly count geodesic cycles but only approximates the count more precisely it gives a lower bound on the number of geodesic cycles of each length this is perfectly suitable for the purpose for which this algorithm was designed but if we are going to count geodesic cycles we would like an algorithm that can be guaranteed to do so exactly in the case of the three patricia networks considered in martin stivala in fact the counts are exact which was verified by manual inspection however this is not the case for all networks as will be shown below in this work in order to count geodesic cycles exactly an algorithm iscyclegeodesic is used this algorithm tests if a given cycle in a graph is geodesic directly by the definition that is for every pair of nodes in the cycle it tests if the distance between those nodes in the cycle is equal to the shortest path distance between them in the graph it is a precondition of this function that the cycle is specified as a list of nodes in order along the cycle so the cycle distance is efficiently computed as min 𝑖 𝑗 𝑘 𝑖 𝑗 where 𝑖 and 𝑗 are the indices of the nodes in the cycle 𝑖 𝑗 ∈ 0 𝑘 1 and 𝑘 is the length of the cycle the distance matrix for the graph can be precomputed or more efficiently a singlesource shortest paths algorithm can be used on demand and the results memoized for reuse this algorithm is implemented by the filtercyclesgeodesicpy python script which takes a graph and on the input stream a list of cycles in the graph and writes to the output stream only those cycles from the input which are geodesic note that because all geodesic cycles are chordless it is more efficient to give as input to this algorithm only chordless cycles which can be enumerated more efficiently than having to enumerate all cycles exponential random graph models and 𝑑𝑘series random graphs as in stivala i use two different families of random graphs exponential random graph models and the 𝑑𝑘series family of random graphs ergms are a random graph model widely used in the social sciences to model social networks an ergm is a probability distribution over graphs where the probability of a graph is a function of a set of graph statistics with their associated parameters the statistics are counts of configurations which represent local structures in the graph such as edges stars or triangles these statistics need not be purely structural but can also include nodal attributes in order to model homophily for example given an observed graph the parameters corresponding to the configurations in the model can be estimated by maximum likelihood with their sign and significance indicating overor underrepresentation given all the other parameters in the model of the corresponding configuration in this work i do not make any interpretation of the estimated parameters but simply use them to simulate a set of graphs from the estimated model for use as a null model in comparing the observed geodesic cycle distributions to those generated from the model in contrast the 𝑑𝑘series random graphs are a series of random graph null models of increasing complexity forming a nested hierarchy for each level of the hierarchy an ensemble of random graphs are generated for which particular statistics are fixed at the values in the observed graph the simplest level of the hierarchy is 0𝑘 in which the density is fixed this is just the erdősrényi random graph model this is followed by 1𝑘 in which the degree distribution is also fixed again a wellknown random graph null model used for motif detection in biological networks for example the next level is 2𝑘 which also fixes the joint degree distribution thus reproducing the degree correlations of the observed graph for practical use in generating ensembles of graphs that resemble empirical networks in relevant statistics orsini et al define the next two distributions in the hierarchy as 21𝑘 and 25𝑘 these are the 2𝑘random graphs with fixed values of average local clustering and average local clustering by degree respectively an advantage of the 𝑑𝑘series approach is that we do not need to contend with the potential difficulties in estimating ergm parameters where for some networks such as most of the fictional character networks considered here it can be difficult or perhaps even impossible to find a converged model further discussion of the relative merits and shortcomings of these approaches can be found in martin stivala martin stivala data the nine networks used in stivala include the three patricia networks from david et al originally used in martin as well as six other networks from a variety of domains as described in stivala the seven fictional character networks used in this work consist of four chapter cooccurrence networks from classic novels one character interaction network from the star wars movie series and two other types of character interaction networks from the harry potter books the four chapter cooccurrence networks considered are from anna karenina by leo tolstoy david copperfield by charles dickens adventures of huckleberry finn by mark twain and les misérables by victor hugo the anna karenina david copperfield and huckleberry finn character interaction networks were downloaded from accessed 1 september 2019 data in the stanford graphbase format was parsed using python code adapted from the charnet project from these networks are illustrated in figures a1 a2 anda3 the les misérables character interaction network was downloaded from accessed 10 july 2019 this network is illustrated in fig a4 the two harry potter networks are dumbledores army and the peer support network for the first six harry potter books the dumbledores army network all networks are undirected clustering coefficient is the global clustering coefficient and assortativity coefficient is the degree assortativity all statistics were computed using the igraph library in r with a tie strength of 4 or 5 resulting in the network shown in everton et al and fig a5 the harry potter peer support network for the first six harry potter books was downloaded from accessed 12 july 2019 the network is directed with a directed edge indicating that character 𝑖 gives peer support to character 𝑗 the network was converted to undirected by changing any directed edge to an undirected edge this network also contains node attributes for school year gender and wizarding house and is illustrated in fig a6 the merged star wars character interaction network was used meaning anakin and darth vader are the same node this network is illustrated in fig a7 summary statistics of these networks are shown in table 1 methods ergm models were estimated and networks simulated from the models with the ergm r package in the statnet software suite networks were simulated from the 𝑑𝑘series random graph models using the randnetgen software the randnetgen program does not simulate graphs from the 0𝑘 distribution so as in martin stivala the igraph r package was used to simulate these networks for each ergm model or 𝑑𝑘series distribution 100 networks are simulated and the box plots generated with the ggplot2 r package represent data from these 100 networks for the networks considered in stivala the same sets of simulated networks from that work were used further details of the ergm models in that work can be found in stivala to count geodesic cycles in a network the cypath software was used to generate all of the chordless cycles which were then given as input to the filtercyclesgeodesicpy script implemented in python with the igraph library which outputs only those cycles that are geodesic to find the longest geodesic cycle in a graph algorithm 41 lic longest isometric cycle from lokshtanov was implemented in python in the longestisometriccyclepy script it is important to note that as described in catrina et al lemma 36 of lokshtanov is erroneous and that therefore the algorithm is only correct for evenlength cycles for oddlength cycles the conditions of this lemma may be met for a particular cycle of length 𝑘 and yet there is no cycle of length 𝑘 in the graph and therefore the algorithm will incorrectly find that there is a geodesic cycle of length 𝑘 there is an example showing this case in catrina et al and it also occurs for example in the patricia graph for 1990 in which the conditions of lokshtanov are met for a geodesic cycle of length 11 and yet there is no such cycle the longest geodesic cycle is of length 10 stivala and fig b1 in order to have the algorithm work correctly for both odd and even values of 𝑘 the auxiliary bipartite graph construction described by catrina et al was implemented in longestisometriccyclepy it is an assumption of this algorithm that the input graph is connected so the implementation handles graphs that are not connected by running the algorithm on each connected component and returning the size of the largest geodesic cycle found in any component this is the longest geodesic cycle in the graph since any cycle must be entirely contained within a single connected component for each set of 100 simulated networks the script to count geodesic cycles was run with an elapsed time limit of 48 hours on an intel xeon e52650 v3 230ghz processor on a linux compute cluster node the iteration over the 100 simulated networks was done serially that is one network at a time if the time limit was reached then only the results for the networks for which the counting could be completed within the time limit are included in such cases where this number was less than 100 this is noted in the relevant figure caption in some cases for the 0𝑘distribution the count cannot be completed within the time limit for even the first network in the set of simulated networks and so there are no results and the results for this distribution are omitted the lengths of the largest geodesic cycles as shown in the plots in section 62 and appendix b are simply the largest geodesic cycles in the distributions computed as described above that have a nonzero count in order to further verify that these are correct the longestisometriccyclepy script described above was used to find the length of the longest geodesic cycle in each network and i verified that these were the same as those found from filtercyclesgeodesicpy 6 results and discussion reproducing earlier approximate results with exact counts in appendix b the results from stivala where geodesic cycles were counted only approximately using the findlargeatomiccycle algorithm are plotted on the same plots as those where the geodesic cycles are counted exactly as described section 2 for patricias 1990 and 1992 networks the results are not any different from those described in stivala in the 1990 network the largest geodesic cycle is extremely unlikely under any of the models while in the 1992 network that the largest geodesic cycle is only of length 4 is extremely unlikely under any of the models the results for the geodesic cycle length distributions are also unchanged with the fit being poor for the 1990 and 1992 networks but acceptable in the case of the ergm only for the 1993 network the situation for maximum geodesic cycle lengths in the 1993 network is slightly different with the exact counting showing that the largest geodesic cycle is more clearly unlikely than is apparent when the approximate method was used along with fig b4 this shows that just as discussed in stivala the ergm shows a better fit to the geodesic cycle length distribution in this network than any of the 𝑑𝑘series distributions for all three patricia networks the observed maximum geodesic cycle length is found to be the same by both methods indeed the fact that the findlargeatomiccycle method found the correct largest geodesic cycle lengths was verified manually on these networks figures b5 b10 show the results for the other networks considered in stivala when using the approximate counting method the ergm shows a good fit for the largest geodesic cycle size however when using the exact counting method this is not the case for the dolphin social network or the kapferer tailor shop network in stivala it was stated that the ergm shows an acceptable fit to the geodesic cycle length distributions for all the nonpatricia networks considered as does the 𝑑𝑘series 25𝑘 distribution however when using the exact counting method we can see that this is not true for the dolphin social network the lazega law firm network the zachary karate club network and the kapferer tailor shop network in the case of the dolphin social network the zachary karate club network and the kapferer tailor shop network the 𝑑𝑘series 25𝑘 distribution also shows a poor fit to the geodesic cycle length distribution when using the exact counting method however in the case of the lazega law form network the 𝑑𝑘series 25𝑘 distribution shows an acceptable fit to the geodesic cycle length distribution when using the exact counting method while the ergm does not in the greys anatomy network the exact counting method shows the same results discussed in stivala both the ergm and 25𝑘 distributions fit the maximum geodesic cycle length well but the ergm also fits the geodesic cycle length distribution well while the 25𝑘 distribution does not as noted in stivala this is because the ergm can reproduce the lack of oddlength cycles in this network by using node attribute information while the 𝑑𝑘series distributions cannot it is however stated in stivala that of the seven fourcycles in this network of which all seven are also chordless only five are also geodesic this is not correct exact counting of geodesic cycles show that all seven are geodesic just as discussed in stivala in the high school friendship network the ergm fits the maximum geodesic cycle length distribution better than the 25𝑘 distribution does fictional character networks as discussed in stivala it can be difficult to estimate ergm parameters for character interaction networks not least because of the presence of a main character often linked to most of the other characters forming a high degree hub node as noted in stivala i was unable to find good converged ergm for the character interaction networks for les misérables david copperfield anna karenina huckleberry finn and hence only 𝑑𝑘series distributions are used here for these networks this is also the case for the star wars network ergm models for the two harry potter networks are shown along with goodnessoffit plots in appendix c parameter estimates of a simple model of the dumbledores army network are shown in table c1 note that despite the geometrically weighted edgewise shared partners term being included in the model the model fit to the edgewise shared partners distribution is not very good in particular it fails to reproduce the pronounced peak in the distribution at 6 or the peak in the degree distribution at 9 this could well be because of the difficulty of an ergm fitting the clique of size 8 clearly visible in fig a5 a clique that includes as we would expect harry potter himself fig 1 shows that indeed the ergm does not reproduce the large clique in the observed network only the 25𝑘 distribution is close to doing so parameter estimates for an ergm for the harry potter peer support network are shown in table c2 i was unable to find a converged model when the gwesp or gwdsp terms were included and so this model is a dyadindependent model as it contains only the edge parameter and nodal attribute parameters relating to a single node or dyad unsurprisingly given the lack of a model term to account for transitivity the goodnessoffit plot shows a poor fit to the edgewise shared partner distribution in attempting to use graph statistics of character networks for book genre classification holanda et al find that all of the networks they examine are disassortative meaning that characters with high degree interact preferentially with those of low degree they therefore concluded that assortativity could not distinguish these genres the works they examined comprised three genres biographical legendary and fiction here we find similarly that six of the seven networks are disassortative the exception with positive assortativity coefficient is the dumbledores army network from the harry potter books this network is notably different from the others in that it is neither a chapter cooccurrence nor character interaction network but a network representing trust or mutual understanding between only a subset of the characters specifically it is an informal dark network of a resistance movement against the death eaters the relatively large clique in this network contributes to it having a positive assortativity figures 2345678show the largest geodesic cycle size and geodesic cycle size distributions for the fictional character networks considered in this work for the four classic novels anna karenina david copperfield huckleberry finn and les misérables it can be seen that the 25𝑘 distribution fits both the largest geodesic cycle size and the geodesic cycle size distribution well as does the 21𝑘 distribution in most cases for the dumbledores army network none of the distributions fit the largest geodesic cycle size particularly well the 𝑑𝑘series 25𝑘 distribution fits the observed geodesic cycle length distribution acceptably while the fit for the ergm is not quite as good so the ergm model does not do as badly at reproducing the geodesic cycle length distribution as it does for the largest clique size relative to the 𝑑𝑘series 25𝑘 distribution for the harry potter peer support network the 𝑑𝑘series 25𝑘 distribution fits the geodesic cycle length distribution very well while the ergm particularly for geodesic cycles of length 5 or less fits it extremely poorly the ergm also does not reproduce the largest geodesic cycle size while the 25𝑘 and 21𝑘 distributions do as already discussed the ergm model for this network is a dyadindependent model and does not fit the edgewise shared partner distribution well so in this case we can see that distributions that reproduce transitivity specifically 21𝑘 and 25𝑘 also reproduce the geodesic cycle length distributions however distributions that do not reproduce the transitivity of the observed network such as 0𝑘 1𝑘 2𝑘 and the dyadindependent ergm also do not reproduce the geodesic cycle length distributions for the star wars character interaction network both the 21𝑘 and 25𝑘 distributions fit the maximum geodesic cycle length well and also fit the geodesic cycle length distribution well with the exception that they both produce significantly more geodesic cycles of length 5 than are present in the observed network conclusions and future work having compared the results in stivala with the results when counting geodesic cycles exactly instead of with the lower bound approximation used originally we see that the results for the three patricia networks are unchanged however for some of the other networks considered what seemed like good fits to the geodesic cycle length distributions for both the 𝑑𝑘series 25𝑘 and ergm distributions are actually not very good fits for either model when the exact counting method is used in one case the 25𝑘 distribution has a good fit to the geodesic cycle length distribution while the ergm does not the essential conclusion remains however that none of the networks examined have maximum geodesic cycle lengths that are extremely unlikely under any of the random graph distributions considered the hypothesis suggested in stivala that fictional character networks and specifically those from works with a single author might have anomalous geodesic cycle length distributions like the patricia networks is not supported on any of the seven fictional character networks examined in this work and the 25𝑘 distribution works in all cases at least one of the 𝑑𝑘series models or ergm reproduces the geodesic cycle length distributions acceptably well hence it seems that there really is something special about the patricia networks in this regard which is not shared by fictional character networks just as with the other networks considered in stivala it seems that fictional character networks even those from works by a single author have a macrolevel structure the geodesic cycle length distribution which can arise naturally from microlevel structures modeled by ergm or fit exactly by the 𝑑𝑘series random graphs the method used here to count geodesic cycles exactly by reading an enumeration of all chordless cycles and testing whether or not each one is geodesic is rather unsatisfactory in that it involves the enumeration of a potentially very large number of candidate chordless cycles the vast majority of which are not geodesic in most cases it would obviously be preferable to directly enumerate geodesic cycles unlike the problem of enumerating chordless cycles there appears to be no published work specifically on enumerating geodesic cycles for example the former is listed in an enumeration of enumeration algorithms and the latter is not the algorithm in lokshtanov for finding the length of the longest geodesic cycle while polynomial in the size of the input graph does not appear to be suitable for enumerating all geodesic cycles and was rather designed to prove the fact that finding the longest geodesic cycle is in p unlike most variants of the longest cycle problem such as finding the longest cycle or longest chordless cycle which are n pcomplete hence the former is computationally tractable and the latter are not in the absence of a more elegant and efficient algorithm and its implementation for directly enumerating geodesic cycles the method used here could potentially be made more efficient simply by using a more efficient method of enumerating chordless cycles the uno and satoh algorithm for enumerating chordless cycles was used in this work not least because it is the only one for which a publicly available implementation appears to exist although this algorithm has been described as the most notable and elegant listing algorithm for this problem at least one algorithm with better asymptotic complexity has been described the enumeration of enumeration algorithms lists in addition the algorithm of wild although this has no known guaranteed performance and neither does the algorithm of sokhn et al although dias et al claims to have an improved algorithm with a parallel implementation for gpu described in jradi et al although there appear to be no published papers specifically on enumerating geodesic cycles one set of papers addresses this issue as part of another problem the work of amaldi et al improves on the horton algorithm for finding a minimum cycle basis of a graph by restricting the candidates to isometric cycles amaldi et al describes an efficient 𝑂 procedure which allows to detect a single representation of each isometric cycle without explicitly constructing the nonisometric cycles this suggests that this procedure from amaldi et al could in fact be used to efficiently enumerate all geodesic cycles the creation of a publicly available implementation of such an algorithm could greatly increase the practicality of examining geodesic cycle length distributions of empirical and random graphs for testing hypotheses about geodesic cycles or for use as an additional goodnessoffit test for random graph models figure a2 david copperfield character interaction network visualization created using the network r package figure a3 huckleberry finn character interaction network visualization created using the network r package figure a4 les misérables character interaction network visualization created using the network r package figure a5 dumbledores army network visualization created using the network r package c2 data availability statement all code scripts and data are available from as noted in catrina et al there is an error in part of this proof in the case of oddlength cycles but the proof can be corrected using the evenlength case with an auxiliary graph construction appendix a visualizations of networks figure a1 anna karenina character interaction network visualization created using the network r package figure a6 harry potter peer support network visualization created using the network r package nodes are coloured according to the house the character is in figure a7 star wars character interaction network visualization created using the network r package appendix b geodesic cycle length distributions for networks from stivala the plots in this section reproduce on the same plots the results from stivala where the geodesic cycles were counted only approximately using the findlargeatomiccycle algorithm labeled findatomiccycles on the plots along with the results counting geodesic cycles exactly labeled countgeodesiccycles on the plots in the plots of largest geodesic cycle lengths the observed largest geodesic cycle lengths are shown as horizontal lines while in the plots of geodesic cycle length distributions the observed values are shown as diamonds the box plots represent values from 100 networks simulated from the distributions as labeled on the plots c1 appendix c ergm models

a geodesic cycle in a graph is a cycle with no shortcuts so that the shortest path between any two nodes in the cycle is the path along the cycle itself a recently published paper used random graph models to investigate the geodesic cycle length distributions of a unique set of delusional social networks first examined in an earlier work as well as some other publicly available social networks here i test the hypothesis suggested in the former work that fictional character networks and in particular those from works by a single author might have geodesic cycle length distributions which are extremely unlikely under random graph models as the delusional social networks do the results do not show any support for this hypothesis in addition the recently published work is reproduced using a method for counting geodesic cycles exactly rather than the approximate method used originally the substantive conclusions of that work are unchanged but some differences in the results for particular networks are described

introduction autism spectrum disorder is a complex lifelong and earlyonset neurodevelopmental disorder characterized by persistent impairments in social communication and interaction across multiple contexts as well as restricted and repetitive patterns in behaviors interests and activities 1 in light of these characteristics both mothers and fathers of children with asd could face unique challenges and parenting demands bearing consequences also on their psychological distress 23 in particular literature has documented that parentchild dyadic exchanges in asd can be characterized by recurrent mismatches less sustained positive emotions and nonsequential patterns of interaction 45 these relational impasses could make it more difficult for the parents to interpret and understand the childs intentions and affective needs constituting a considerable source of stress therefore parents may often perceive the interaction with their child as unrewarding and challenging experiencing negative feelings which can significantly increase parental stress and mental health difficulties 67 higher parental stress and mental health problems in parents of children with asd can pose further risks for parentchild relationships generating a cascade of adverse effects on parenting functioning 89 parenting a child with autism spectrum disorder in italy and japan a crosscultural perspective parenting refers to the process of promoting the social physical emotional and intellectual development of a child 10 providing a supportive and nurturing early social environment through adequate and prompt sensitive behaviors 11 according to a processual model 12 parenting is determined by the complex interplay between several factors such as childrens and parents characteristics and socialcontextual dimensions focusing on the socialcontextual level the socialization process carried out by parents is deeply influenced by the culture in which they are immersed 13 based on hofstedes cultural dimensions theory 14 japanese culture is considered a collectivistic society since the harmony and the interest of the group tend to prevail over the individuals ones in such societies social harmony is highly valued and individuals are expected to inhibit the expression of their own needs and attend to the needs of others in their ingroup 15 parents in collectivistic cultures try to promote these values through parenting practices that encourage children to view themselves as part of the integrated whole of their ingroup and not to emphasize their differences from others 16 17 18 19 on the other hand italian culture is defined as individualistic since the interests of the individual overcome the benefits of the group in individualist societies independence selfinterest and selfreliance are highly valued in the socialization process accordingly parents tend to promote autonomy exploration and uniqueness in their children and the individuals sense of identity is expected to develop more according to personal characteristics than in conformity to their group membership 1415 these cultural differences are also reflected in the way societies and families deal with children with atypical development in the individualist communities the dominant philosophy is to treat these children as much as possible as children with typical development whereas in the collectivist communities the disability is more susceptible to stigmatization and could be seen as a shame for the family 1415 as childrens behaviors and attitudes are considered as a direct reflection of the parents childrearing capabilities these distinct cultural views also contribute to the differences in health systems and social inclusion strategies for children with special needs for instance while in italy most children with special needs including children with intellectual disabilities are integrated into the regular school system in japan children with intellectual disabilities are encouraged to attend special schools whereas children with special needs without intellectual disabilities join regular schools where they have the option to attend support classes taken together the challenges associated with rearing a child with asd could differ among the japanese and italian cultures as divergent social models and policies regulate the experience of parenting children with disabilities even if there is a global awareness of asd and a similar prevalence among countries we have insufficient knowledge about its impact on children and their families in different world areas and cultures 20 therefore crosscultural comparisons may be particularly relevant since cultural differences could not only influence the perception of child symptoms 21 but could also impact parental attitudes and behaviors affecting several parentchild domains including parental stress and styles parenting stress in mothers and fathers of children with asd among several parenting dimensions most of the research concerning parenting and asd has focused on parental stress mainly on mothers since they are often the childs primary caregiver parenting stress is defined as a set of processes that lead to adverse psychophysiological reactions arising from attempts to adapt to the demands of parenthood 22 in general literature widely showed that mothers of children with asd experience higher levels of parenting stress than mothers of children with other neurodevelopmental disorders 23 and typical development 24 consistently higher levels of parenting stress have been found both in japanese mothers 20 and italian 25 parents of children with asd when compared to families of td children while parenting stress findings have been well corroborated for mothers only a few studies specifically focused also on fathers of children with asd 26 mainly reporting higher stress levels than fathers of td children 27 both in italy 2528 and japan 29 of note only a limited number of studies focused on gender differences in parenting stress providing mixed evidence some findings revealed that mothers experience higher levels of stress and involvement than fathers 27 29 30 31 while others reported similar stress levels for both parents 3233 including a study on an italian sample 28 social style in mothers and fathers of children with asd parenting styles are defined as the constellation of attitudes expectations and beliefs concerning the upbringing of a child that results in a set of parental behaviors used in the daily interactions with their own offspring 34 specifically social style refers to parenting behaviors in the context of parentchild dyadic interpersonal exchanges involving the expression of parental sensitivity affect and mutual reciprocity 3536 with respect to the italian context research on parenting styles indicated that mothers highly regard their childrens socioemotional expressiveness and encourage their development through the promotion of infants interactions with people inside and outside of the family 37 accordingly italian parents tend to value sociability liveness and activity in their children and declare interacting with their babies more in the social and interpersonal domain 38 in japan observational studies showed that mothers engage in more social interaction 39 and less didactic activities 40 with their children than europeanamerican mothers japanese mothers considerably value social competence in their infants and tendentially engage in more symbolic play and empathy training with their children 40 41 42 although the evidence that parental styles and behaviors play a key role in the development of children with asdas it does with td childrenis increasing this area of research is still underinvestigated 8 with the few studies comparing parental styles of parents of td and asd children yielding contrasting results both in eastern and western cultures 8 43 44 45 46 47 48 49 concerning gender differences in parenting styles it has been reported that maternal and paternal behaviors diverge in various ways 11 for instance father involvement in infancy and childhood is quantitatively less than mother involvement 5051 as is the case of td also in families of children with asd mothers dispense more time with their children and have more caregiving and managerial roles compared to fathers whose interactions are characterized by play activities 28 this also reflects differences in the strategies used by fathers and mothers of children with asd in general fathers tend to be more directive and less active in engaging their children with asd 5253 while mothers of children with asd reported taking on more social behaviors than fathers 28 in addition to child diagnosis and parent gender research suggests that parenting behaviors and styles may be regulated by parents cognitions and emotional states in particular higher levels of parenting stress have been associated with less positive behaviors in the context of parentchild dyadic interpersonal exchanges 54 particularly in parents of children with asd 22 a recent chinese study conducted on families of children with asd confirmed the significant effect of parenting stress on parenting behaviors emerged not only in mothers but also in fathers 55 to summarize mothers and fathers of children with asd tend to report higher parenting stress compared to parents of children with td regardless of culture literature on gender differences related to parenting stress provides mixed findings with respect to parenting behaviors studies suggested that mothers engage more frequently than fathers in sensitive behaviors in the interaction with their children research on eastern countries has shown that parents of children with asd exhibit less positive parenting compared to parents of nonasd children however it is still unclear whether this result is culturespecific or if western parents of children with asd show similar levels of social style than their eastern counterparts moreover it is important to consider that parenting stress seems to have a significant impact on maternal and paternal behaviors limiting the ability to provide optimal and sensitive parenting especially in parents of children with asd although literature has widely investigated maternal dimensions particularly parenting stress little attention has been paid to fathers of children with asd other crucial parenting domains such as parenting style have not been sufficiently addressed so far importantly both parenting stress and styles can be influenced by cultural models since individualistic and collectivistic countries may endorse different sociocontextual views related to atypical neurodevelopment childrearing practices and gender roles in parenting however no previous studies on the families of children with asd examined similarities and differences in parenting stress and social parenting style comparing mothers and fathers of eastern and western countries the current study in the present study we aimed to investigate potential differences in parenting stress and parenting social style between italian and japanese mothers and fathers of children with asd to examine the predictive role of sociodemographic characteristics childs features on parenting stress in parents of children with asd in italy and japan to study the predictive role of culture parents sociodemographic characteristics childs characteristics and parenting stress on the social parenting style in italian and japanese parents of children with asd regarding our first aim we expect to find higher levels of parenting stress in japanese parents than italian parents due to the higher social pressure aimed at maintaining group harmony which characterizes the collectivistic background no gender differences were expected in both samples on parenting stress secondly we hypothesized that japanese mothers and fathers would engage less in the social domain of parenting than italian parents since their need to act in conformity to their group membership may hamper their engagement in the challenging parentchild interactions encouraging the suppression of disagreeable emotional states with respect to gender differences we hypothesize to find higher levels of social parenting style in mothers than fathers regardless of culture concerning our second aim we expected that country of origin and childs characteristics would predict parenting stress of parents of children with asd finally our expectation about the third aim was that parents gender and parenting stress would be predictive of social parenting style in both cultures materials and method participants and procedures the present study involved 181 parents of schoolage children or for the verbally impaired subjects through the leiter international performance scalerevised family socioeconomic level was in the medium range as measured with the hollingshead fourfactor index 63 japanese participants were 89 parents of 47 children with asd they were recruited from the research centre for child mental development of kanazawa university where they were participating in another study the intelligence quotient of the japanese children was measured through the kaufman assessment battery for children 64 and fell within the normative range family socioeconomic level was in the medium range according to the hollingshead fourfactor index 63 all measures based on questionnaires were collected via mail from the japanese parents more detailed participants characteristics are presented in table 1 both japanese and italian participants provided their formal informed consent in participating in the study data were collected according to european current regulation and following the helsinki declaration principles as regards the italian participants all procedures of our study were in accordance with the ethical standards of the italian association of psychology and the ethics committee of the faculty of psychology and cognitive science of the university of trento with respect to the japanese sample the study has been approved by the local irb local committee measures 221 childrens intelligence quotient for assessing childrens iq according to the age of the child the wechsler intelligence scale for children wechsler preschool and primary scale of intelligence and leiter international performance scalerevised alternatively to wisc in verbally impaired subjects have been used for the italian sample for japanese children the iq assessment was carried out with the japanese version of the kaufman assessment battery for children 64 as this battery is more used in japan as an iq measure all these scales use standard scores that have a mean of 100 and a standard deviation of 15 allowing direct iq comparisons of intelligence the wisc leiterr and the kabc results have been standardized in order to have comparable scores across instruments autism symptoms severity to classify the asd severity of the children we used the autism diagnostic observation schedule and its second edition modules scores ados tests are semistructured standardized assessments of social interaction communication play and imaginative use of materials for people suspected of having asd 56 57 58 we transformed raw scores following the manuals protocol and calculated the diagnostic algorithm in particular the total score of the ados was confronted with the cutoffs of each ados module being module 1from no word to very few words are autism 16 autism spectrum 11 module 1some words are autism 12 autism spectrum 8 module 2equal or more than 5 years are autism 9 autism spectrum 8 module 3 are autism 9 autism spectrum 7 from this we generated a dichotomous variable one including all participants scoring above the modules cutoffs for autism and one including all participants that were above the modules cutoffs for the autism spectrum but below the autism ones parenting stress the parenting stress indexshort form is a widely used selfreport questionnaire for the assessment of parenting stress it has been developed on account of various exploratory factor analyses of the full psi 66 and it consists of three subscales of 12 items parental distress parentchild dysfunctional interaction and difficult child the sum of the three subscales yields to a total stress scale specifically the pd subscale indicates the distress felt by a parent because of personal factors related to parenting such as low social support or parental depression the pcdi subscale evaluates if the parent sees hisher interactions with the child as positiverewarding or negativeunsatisfying the dc subscale assesses the childs behavioral characteristics that make himher easy or difficult to manage as a result of hisher temperament andor noncompliant defiant or demanding behavior 67 additionally the psisf contains a defensive responding scale signaling the degree to which the parent might be trying to give a more positive selfimage deny stress or minimize problems in their relationship with the child parents responded to the 36 items on a 5point likert scale indicating the degree of agreement with each statement ranging from 1 to 5 the ts score is a measure of the parents overall parenting stress all the scales have been demonstrated to have a high internal consistency 6568 since the psisf was not available for purchase in japan at the time of this study we used the japanese psi full version for the japanese parents the psisf is a direct derivation of the psi full version for this reason we were able to construct the psisf in japanese selecting the corresponding items from the japanese version of the psifull parenting social style the parental social style was assessed by the social exchange scale of the parental style questionnaire a selfreport questionnaire to measure individual differences in parenting behaviors domains for italian parents we used the italian version of the psq 36 and for japanese parents an ad hoc translation was created starting from the english original version following standard backtranslation techniques and seeking for semantic linguistic and cultural equivalence 70 parents were asked to rate each item on a 5point likert scale ranging from 1 to 5 based on how often they display the described behavior the social exchange scale is formed of 5 items that assess how often parents engage in dyadic interactions with their children characterized by sensitivity expressions of affection and positive responsiveness to the child the scales score is formed by the unweighted mean of responses to the five items an example of a question regarding the social exchange style is i provide my child with positive affectionate displays of warmth and attention the scale has shown good internal consistency and construct validity 2835363869 data analysis descriptive statistics by country are displayed in table 2 firstly we checked for normality of the distribution skewness and kurtosis of the study variables and outliers then bivariate correlations were separately performed to test the association among the study variables next as preliminary analyses we checked for potential differences between countries on categorical and continuous control variables specifically we examined potential group differences between italian and japanese samples in child gender autism severity as well as in maternal and paternal age child age intelligence quotient and family socioeconomic status with regards to the first aim of the study we performed a twoway multivariate analysis of variance with psisf total stress and subscales as dependent variables similarly a twoway anova has been conducted using the parenting social style scale as a dependent variable with respect to our second aim to investigate potential predictors of parenting stress we performed a hierarchical multiple regression including three blocks in the first block we included culture then parents gender age and family ses were added in the second block next the childs iq and autism severity were entered in the last block finally the same regression model was used to examine potential predictors of the social parenting style but a fourth block was added to the overall model including the three psisf subscales in general the variables entrance was forced according to our research purposes we also checked the variance inflation factors for both regression models in order to determine multicollinearity among the predictors regressors with a vif value smaller than 4 were considered acceptable and thus included in the models all the statistical analyses were conducted using the spss package results crosscultural comparisons bivariate correlations among the study variables for both countries are shown in the supplementary materials with respect to the group comparison on the control variables chisquared tests and the manova yield nonsignificant results since no differences emerged respectively for child gender autism severity child iq family ses and child maternal and paternal age focusing on the first study aim results of the two way manova revealed statistically significant differences in parenting stress based on country 770 p 0001 wilks λ 0882 partial η 2 012 whereas no significant effect of parent gender and no interaction between country and gender were found specifically univariate analysis showed a main effect of country on parental distress 2260 p 0001 and difficult child subscales 699 p 001 as well as on total stress scale 1416 p 0001 with japanese parents showing higher scores compared to italian parents as regard to group differences in parental social style the twoway anova highlighted a main effect of the country 866 p 001 with italian parents reporting higher scores compared to japanese parents moreover a main effect of parent gender 1204 p 0001 emerged with mothers showing higher levels of parental social style than fathers predictors of parental stress according to our second aim we performed hierarchical regression analyses to investigate the contribution of specifically selected sociodemographic parenting and child variables on parental stress the overall model explains around 13 of the variance 430 p 0001 in the first step country of origin significantly predicted parental stress explaining 7 of the variance whereas the second block including parent gender parent age and family ses did not add a significant contribution to the model in the final model there was a significant predictive effect of country and child autism severity adding significant contribution to the overall model specifically being a japanese parent and having a child with higher autism severity predicts higher levels of parenting stress predictors of parental social style we replicated the abovedescribed regression model to examine the predictors of parental social style by adding a fourth block including the three psisf subscales this hierarchical regression analysis revealed that the predictors explain around 32 of the total variance 1027 p 0001 country of origin was significant in the first block with being an italian parent associated with a higher level of parental social style in the second block only country of origin and parent gender were significant whereas no predictive effect of parent age and family ses was found 487 p 0001 in particular being a mother predicted a higher level of parental social style adding a significant contribution to the model although the model remains significant 344 p 0003 the third block did not add a significant contribution since the entered variables were both not significant in the final model country of origin parent gender and stress related to parentchild dysfunctional interaction showed a significant predictive effect on parental social style conversely child age parent age family ses child iq and autism severity as well as parental distress and difficult child psi subscales did not contribute significantly to the overall model discussion parenting stress and styles are considered two critical domains in the field of parenting and asd since social communication impairments may pose specific challenges for mothers and fathers straining parentchild interaction however only a limited number of studies examined potential gender differences in parenting stress and style in families of children with asd providing contradictory results moreover although these two dimensions can be influenced by cultural tendencies toward childrearing and atypical development previous studies did not address potential differences between individualistic and collectivist countries focusing on families of children with asd therefore to fill this gap this crosscultural study aimed at investigating potential gender and cultural differences in parenting stress and social style between italian and japanese mothers and fathers of children with asd in addition we examined the contribution of culture child and parenting variables that could influence parenting stress and style in the context of asd gender and crosscultural differences in parenting stress and social style to the best of our knowledge this is the first study testing potential crosscultural differences in parenting stress and social style between japanese and italian parents of children with asd firstly as hypothesized parenting stress was found to be higher in japanese parents compared to italian parents particularly on the parental distress subscale which refers to the extent to which parents feel competent restricted conflicted supported andor depressed in their role as a parent this result may be ascribed to the cultural backgrounds that characterized collectivistic society as is the case of japan in fact collectivistic cultural tendencies such as trying to adjust them to a typical standard may increase their parenting stress in mothers and fathers of children with asd parenting a child with atypical neurodevelopment entails various challenges that may be at odds with a collectivistic approach which relies on attending family and community harmony 16 17 18 in this sociocultural context asd sociocommunicative impairment can make adherence to group common values and norms harder to accomplish constituting a considerable source of stress for parents for instance when mothers perceive themselves as ineffective in managing their childrens difficult behaviors as may occur in the context of asd they are more likely to experience feelings of guilt and shame perceiving to fail in their role in the eyes of the community and thus arousing parenting stress 19 second no differences in parenting stress were found among mothers and fathers of children with asd regardless of culture although prior research provided mixed results our finding is in line with other studies reporting similar levels of parenting stress in both parents 3233 including a study conducted on an italian sample 28 this result confirmed the importance of including fathers in asd early intervention 26 since they may experience higher levels of parenting stress just like mothers focusing on parenting social style our findings revealed significant crosscultural and gender differences according to our hypothesis italian parents scored higher than japanese parents on the parenting social style scale reporting to engage more frequently in sensitive responsive affectionate dyadic interactions with their children a possible explanation of this finding is that japanese parents could show less positive engagement with their children when they show difficult behaviors in social situations since group membership and child social competence are prioritized instead of the childs affectional needs in the context of asd externalizing behaviors arousal dysregulation or exaggerated expression of negative affect may be considered unsuited for the maintenance of group harmony additionally at this range of child age japanese parents are more likely to fulfill child independence and to express less emotional regulation than italians moreover mothers reported higher levels of parental social style compared to fathers regardless of culture our finding is in line with a previous study by ozturk and colleagues 28 conducted on italian mothers and fathers of children with asd this result may also be explained by the divergent style of parenting used by fathers which tends to be more directive energetic and competitive with their children than mothers 50 51 52 71 furthermore mothers are more involved in childcare than fathers spending more time with their children 51 and thus having more opportunities to engage in social dyadic exchanges predictors of parenting stress and social style in japanese and italian parents of children with asd with respect to parenting stress in mothers and fathers of children with asd country and the severity of asd symptoms emerged as the only significant predictors first as observed on group differences the role of social pressure related to the sociocultural collectivistic view may have increased the levels of perceived parenting stress in japanese parents therefore it becomes essential to note that cultural background could have an impact on the experience of mothers and fathers influencing the perception of their parental role and the burden associated with the caregiving practice moreover japanese parents can be more susceptible to selfblame since their cultural background endorses a roleoriented approach in which child behaviors are considered a reflection of parental abilities and competence 72 according to the traditional literature on parenting and asd 32 we also found that parenting stress levels are associated with child symptoms severity in this regard it is plausible that children with higher asd severity show higher levels of dependency toward their parents requiring intense caregiving support which may escalate parental strain and worries thus caring for a child with severe asd symptoms could constitute a specific risk factor for both mothers and fathers across countries making it more difficult to balance their psychological and coping resources with the parentingrelated demands in fact higher impairment in interpersonal relatedness and social communication could pose additional challenges for parents affecting their sense of competence and efficacy 73 additionally previous studies 2025 also demonstrated a significant link between parental stress and behavioral and emotional problems related to the asd diagnosis it is important to consider that parenting distress in italian and japanese parents of children with asd has been found to be associated with parental depression the balance of parents diverse roles in their life lack of social support attachment difficulty anxiety about the childs future and caregiving burden and quality of parentchild interaction 2028 furthermore we found that country gender and parenting stress related to parentchild dysfunctional interaction have a predictive effect on parenting social style as previously highlighted for group comparison on parenting social style the effect of the country could be ascribable to the divergent cultural approach on childrearing which characterize individualistic and collectivistic societies for instance parents coming from individualistic countries as is the case of italy are focused on promoting child uniqueness since individual development is expected to be shaped more by personal characteristics than group expectations and needs 15 accordingly italian parents reported interacting with their children more on the social and interpersonal level compared to other parenting domains 38 conversely japanese mothers and fathers could show less engagement in the social domain of parenting than italian parents given that the more frequent display of negative emotions associated with asd may be in contrast with their ingroup values and norms and thus less tolerable for parents regardless of the country we also found that mothers showed a higher parenting social style with their children than fathers according to our hypothesis it is likely that mothers across cultures assume more caregiving responsibilities providing higher support to their children in the social exchange in line with previous literature on typical and atypical development mothers tend to engage in highly responsive behaviors toward their children in the context of dyadic interaction promoting their socioemotional expressiveness and competence 283772 importantly we also found a significant link between parenting stress related to parentchild dysfunctional interaction and parenting social style across countries specifically higher maternal and paternal stress levels related to feelings of disappointment rejection or alienation byfrom the child predict fewer expressions of affection and positive responsiveness to the child our findings extended previous studies conducted only on eastern countries revealing the effect of parenting stress on maternal and paternal care in families of children with asd 55 interestingly parenting functioning in the dyadic exchanges with the child seems more related to relational stress instead of parenting stress generated by personal adjustment to parenthood or child individual difficulties it is important to note that parenting stress in asd is associated with more authoritarian and permissive parenting and higher levels of overprotection in asd 4655 which have been found to be associated with negative child outcomes in asd 74 finally no effect of child iq and family ses on both parenting stress and social style were found although prior research revealed a significant effect of child iq 7576 other studies have shown that cognitive functioning is not a salient feature in predicting parenting stress 32 moreover in our sample most of the children showed high cognitive functioning since they scored above 70 on the developmental assessment similarly the lack of significant effect of family ses on parenting stress may be due to the poor variability of our samples on this dimension given that no effect of asd symptoms severity has been observed on parenting social style it is plausible that other variables such as child externalizing behaviors or emotion regulation processes may intervene in shaping maternal and paternal sensitive and affectional behaviors in the context of dyadic interaction conclusions the current study supports the traditional models of determinants of parenting 1277 according to which maternal and paternal parenting are determined by multiple factors including parent and child variables as well as sociocultural dimensions firstly our results highlight the need to evaluate the influence of cultural tendencies on parenting stress perception and dyadic interactive style also in families of children with asd this is of particular relevance since the sociocultural view on childrearing and atypical neurodevelopment may play a pivotal role in shaping parental cognitions and practice to sum it up our findings suggest that a collectivist cultural approach could make japanese parents more susceptible to parental stress related to feelings of competence and restriction in their role as a parent by contrast italian parents of children with asd reported engaging more frequently in responsive and affectional behaviors compared to japanese parents in this case individualistic cultural models seem to promote more affectionate parenting focused on sharing positive affect and supporting child initiative on the other hand parents who endorse a collectivistic approach could be more prone to minimize the expression of disagreeable effects or inadequate child initiatives to fulfill group needs and be perceived as competent by the community other findings are independent of culture for instance autism severity was found to be predictive of parenting stress for both japanese and italian parents focusing on parenting social style mothers reported higher levels of social exchange with their children parenting stress related to parentchild dysfunctional interaction strongly predicted sensitive responsive and affectionate parenting across countries in both mothers and fathers the current study also has clinical implications highlighting the importance of supporting both mothers and fathers of children with asd through specific interventions that take into account parental cultural background in particular japanese parents of children with asd may benefit from interventions aimed at reducing selfblame and worries associated with feelings of competence and parental role strain fathers should also be included in supporting programs for parents of children with asd since they showed similar levels of parenting stress to mothers tailored parentmediated interventions are recommended to boost parentchild interaction in asd and to decrease feelings of rejection and alienation in parents this could be of relevance in helping parents to handle child dysfunctional behaviors in the context of dyadic interaction notably our findings should be interpreted with caution since some limitations need to be acknowledged the heterogeneity of our sample in terms of child age cognitive functioning and asd severity may constitute a limitation in addition we dichotomized the asd severity variable due to the multiple versions and modules used for the assessment and thus it was not possible to use a continuous dimension for the statistical analysis with respect to crosscultural comparison it is important to note that measurement invariance has not been tested to confirm that the same construct is being measured across groups moreover cultural dichotomy may have simplified the explanations attributed to differences and properties of the parental stress between the countries given that couples were considered in this study it would have been appropriate to include a measure of paternal involvement in childcare to include this variable as a covariate finally we do not have a measure of child difficult behaviors and emotion regulation which can strongly impact parenting stress and style future research should replicate our results using larger samples and including other eastern and western countries to investigate similarities and differences across cultures in families of children with asd we suggest that to examine individuals differences in stress and styles the cultural dichotomic framework should be extended by considering other crucial sociocultural and individual domains since both mothers and fathers are included dyadic statistical models can be used to account for the interdependence of the data the assessment of parenting style can be improved by using standardized observational procedures and not only selfreported measures this could help in identifying specific components of the parentchild relationship including specific features which characterize both maternal and paternal interactive styles moreover longitudinal study designs are recommended to test predictive effects on parenting variables supplementary materials the following are available online at 103390brainsci11111419s1 table s1 correlation between variables of italian mothers table s2 correlations between variables of italian fathers table s3 correlations between variables of japanese mothers table s4 correlations between variables of japanese fathers data availability statement not applicable informed consent statement both japanese and italian participants provided their formal informed consent in participating in the study data were collected according to european current regulation and following the helsinki declaration principles

parents of children with autism spectrum disorder asd face unique challenges which may affect parenting functioning however little is known about gender and cultural variations in parenting stress and styles in these families the aims of this study were to investigate 1a the differences in parenting stress and 1b social style between italian and japanese mothers and fathers of children with asd 2 the predictive role of culture sociodemographic and childs characteristics on parenting stress 3 the predictors of the social parenting style including parenting stress dimensions the study involved 92 italians and 89 japanese parents of schoolage children 512 years with asd who completed the parenting stress index and the parenting style questionnaire results revealed that japanese parents showed higher parenting stress and less engagement in social style than italians across cultures mothers used more social style than fathers being japanese and having a child with greater asd severity predicted higher levels of parenting stress we also found that country parents gender and stress related to the dysfunctional interaction were significant predictors of parenting social style our findings highlight the importance of a crosscultural approach to better understand the experiences and needs of mothers and fathers of children with asd

introduction health begins in the mouth according to ongoing scientific studies in the medical sector 1 nowadays maintaining good oral health is important for more than just maintaining the condition of our teeth as adequately supported by the literature it also serves as a foundation for our bodys whole health and wellbeing an essential human right is the right to health an individual can live a happy life boost productivity and enjoy the quality of life if they are healthy 2 in addition to causing pain oral disorders can also create social embarrassment and set off physiological processes that make the entire body suffer 3 however certain ethnic groups continue to practice traditional values and beliefs while remaining geographically or socially isolated these groups also tend to rely on traditional indigenous methods of treatment rather than accessing oral health treatments when necessary 4 they are frequently referred to as the tribal population and are regarded as the native inhabitants of the area native to the state of tamil nadu is the tribal group known as the narikuravar they deal with concerns including poverty illiteracy communication difficulties inadequate healthcare and social discrimination which are prevalent but significant 5 6 past studies of the tribal narikuravar populations oral health state and understanding of oral hygiene measures revealed that both were in very poor condition necessitating greater dental care 7 additionally this community tends to use traditional indigenous healing methods rather than seeking out oral health care when they are needed 8 a further investigation found that narikuravar women used allopathic healthcare less frequently than other women because they encountered stigma and discrimination when seeking medical attention 9 the impact of stress on the development of the illness has emerged as a key subject in current psychosomatic research oral healthrelated qol is a multifaceted concept just as healthrelated qol that includes aspects like survival illness and impairment social psychological and physical function and disability oral health perceptions and opportunity 10 the oral impacts on daily performance scale is one of the qol tools for oral health that measures how oral diseases affect peoples daily lives oidp is a tool that is useful for population surveys 11 in addition to being userfriendly it evaluates behavior rather than emotional state researchers have analyzed each stress measurement method and its limitations as research tools in psychosomatic medicine several tools that have been created to evaluate individual stress levels can be used to get a more accurate measure of personal stress one is the perceived stress scale a wellknown tool for measuring stress 12 13 although it was created in 1983 the tool continues to be a popular option for assisting us in comprehending how various circumstances affect our feelings and our perception of stress because of the various stigma and stress associated with seeking treatment for oral health there is compromised oral health care in this community 14 with this background our study aimed to assess the selfperceived stress and oral healthrelated quality of life among tribal gypsies in chennai materials and methods the study was conducted among the narikuravar tribal gypsies living in thirumullaivoyal chennai in april 2022 every gypsy who is a chennai district resident and is over 18 was required to meet the inclusion criteria participants in the study were those who gave their consent and were willing to participate people under 18 who were bedridden and unable to engage were omitted the current studys participants were all given information about it and received assurances of confidentiality all of the studys subjects provided their informed consent the present study included 320 study participants in total using the perceived stress scale and the oidp scale15 the tribal populations selfperceived stress and oral health quality of life were evaluated microsoft excel 2017 was used to collect tabulate and perform statistical analysis on the data spss software version 230 was used for the analysis to determine the statistical significance with p0005 descriptive statistics and pearsons correlation test were used results table 1 shows the demographic data of population figure 1 depicts the stress level among tribal gypsies in chennai highstress level of 306 moderate stress level of 563 and lowstress level of 131 figure 2 depicts the impact of stress on the daily performance of tribal gypsy in chennai which includes eating and enjoying food smiling and showing teeth without embarrassment cleaning teeth sleeping and relaxing and enjoying contact with people 759 of people have reported no impact of stress on daily performances for past 6 469 impactimpact of stress affecting their daily life nearly every day 247 once or twice a week 172 once or twice a month 81 less than once a month table 2 shows the correlation between stress levels and sleeping and relaxation among tribal gypsies in chennai showing a high association between highstress levels and their impact on everyday life a chisquare test was done and the association was found to be statistically significant pvalue 0000 p 005 table 3 shows a correlation between stress levels and their contact with people among tribal gypsies in chennai high stress levels are associated with a great impact on daily performance with contact with peoplea chisquare test was done and the association was found to be statistically significant pvalue 0001 p 005 table 4 shows a correlation between stress levels and their gender females had higher stress levels than males a chisquare test was done and the association was found to be statistically significant pvalue 0000 p 005 discussion compared to nonindigenous majority populations indigenous peoples typically experience more exclusionmarginalization and worse health status which includes decreased oral health and less access to dental treatments 16 when compared to nonindigenous people those who identify as indigenous often suffer greater barriers to social resources in all facets of life their health state is generally worse they typically have less access to and use of healthcare and their healthrelated data are commonly missing erroneous or incomplete the global burden of oral diseases such as dental caries periodontal disease and oral cancer is significant and rising especially in lowand middleincome nations dental problems are a major cause of morbidity and poor healthrelated quality of life in indigenous communities where data are available 17 when combined with other chronic conditions psychological stress is a factor in systemic poor oral health previous research has demonstrated that people who perceive stress as being higher also report having worse oral health and dental insurance and socioeconomic status have an impact on this association 18 additionally our study shows a highstress level of 306 a moderate stress level of 563 and a lowstress level of 131 among tribal gypsies in chennai figure 2 depicts the impact of stress on the daily performance of tribal gypsy in chennai which includes eating and enjoying food smiling and showing teeth without embarrassment cleaning teeth sleeping and relaxing and enjoying contact with people 759 of people have reported no impact of stress on daily performances for past 6 months 469 impact of stress affecting their daily life nearly every day 247 once or twice a week 172 once or twice a month 81 less than once a month table 2 shows the correlation between stress levels and sleeping and relaxation among tribal gypsies in chennai showing a high association between high stress levels and their impact on everyday life table 4 shows a correlation between stress levels and their gender females had higher stress levels than males given these results more attention has to be paid to the role of psychological stress in the emergence of oral disease as well as how perceived stress affects disparities in oral health status as reported by individuals in addition to what is required to reach a state of health in the oral environment of less stressed people patients experiencing stressful lives may differentially demand closer monitoring and more careful management of their oral health in particular for the underprivileged and uninsured addressing psychosocial dental care issues may have healthpromoting consequences 19 however it is also noted that there are cultural impediments such as the gypsy communitys pride in independence and the acceptance of poor health 20 low expectations and mistrust of healthcare services and professionals may result from these various issues in addition to poor quality care that does not meet healthcare needs 21 interventions to raise awareness about oral health care are frequently multifaceted but important for indigenous people in lowering their stress and stigma levels 22 increased healthcare use is linked to improved health behaviors higher standards of care and trust in services and providers strategies for community participation have the power to increase confidence and guarantee that services are adapted to the needs of certain communities 23 community engagement is one of several overlapping terms used to describe activities intended to enable communities to take part in decisions that affect their lives and enhance their health and wellbeing including planning designing delivering and evaluating health services 24 to enhance their oral health status steps must be taken to increase their access to care and reduce their barriers 25 conclusion inattention to oral health is a common trait in the narikuravar community many nomads had oral health perceptions significantly correlated with their traditional habits and their oral health had worsened to enhance their oral health status steps must be taken to increase their access to care and reduce barriers conflict of interest the authors declare no conflict of interests all authors read and approved final version of the paper authors contribution all authors contributed equally in this paper

introduction certain ethnic groups continue to practice traditional values and beliefs while remaining geographically or socially isolated these groups also tend to rely on traditional indigenous methods of treatment rather than accessing oral health treatments when necessary past studies of the tribal narikuravar populations oral health state and understanding of oral hygiene measures revealed that both were in very poor condition necessitating greater dental care poor oral health also implies that their general health will be compromised affecting their ability to work as well aim to assess the selfperceived stress and oral healthrelated quality of life among tribal gypsies in chennai materials and methods the study was conducted among the narikuravar tribal gypsies living in thirumullaivoyal chennai in april 2022 the present study included 320 study participants in total using the perceived stress scale 1983 and the oidp scale the tribal populations selfperceived stress and oral health quality of life were evaluated to determine the statistical significance with p 0005 descriptive statistics and pearsons correlation test were used results our study shows a highstress level of 306 a moderate stress level of 563 and a lowstress level of 131 among tribal gypsies in chennai the correlation between stress levels and sleeping and relaxation among tribal gypsies in chennai shows a high association between highstress levels and their impact on everyday life a chisquare test was done and the association was found to be statistically significant p value 0000 p 005 conclusion many nomads had oral health perceptions significantly correlated with their traditional habits and their oral health had worsened to enhance their oral health status steps must be taken to increase their access to care and reduce barriers

introduction adolescence is a key stage in sexual development where beliefs about appropriate sexual behaviour are formed it is well documented that many harmful behaviours manifest during adolescence with approximately half of sexual offenders reporting their first assault during this time due to its increased and unrestricted availability on the internet pornography use is a part of many adolescents experience the rising prevalence of pornography use mostly but not exclusively among male adolescents prompted concerns among researchers and policy makers about the impact of pornography on youth sexual socializationparticularly regarding the acquisition of sexual scripts which may increase the risk of sexual aggression a number of theories have been proposed to explain possible association between pornography use and sexual aggression many are grounded in sexual script theory and banduras theory of social learning which argue that individuals may model their sexual behaviour after pornographic depictions others endorse the selective exposure hypothesis and argue that preexisting preferences and specific attitudes underlie both the selection of sexualized media and sexual aggressiveness to address these important and socially relevant issues this study explores the association between male adolescents pornography use and sexual aggressiveness using longitudinal design and withinperson latent variable analytical approach pornography use and sexual aggression the body of literature which has examined the link between pornography and sexual violence has found evidence of an effect for a small proportion of individuals for example longitudinal research of north american adolescents involving 6waves of data collection showed the use of violent pornographic content which was defined as depicting one person physically hurting another person while doing something sexual was associated with sexual aggression and coercion even after controlling for several other risk factors for sexual aggression similar results were reported by another study that found that after controlling for risk factors like nonsexual aggression alcohol use and witnessing violence within the home the use of violent pornography was associated with significantly higher odds of sexual aggression findings from a 2009 longitudinal study found that engagement with mainstream pornography defined as xrated movies in early adolescence predicted sexual harassment perpetration among american late adolescent males more recently tomaszewska and krahe found that consensual pornography use defined as sex photos presentations of sexual intercourse presentations of other sexual acts for example oral sex masturbation and films in which the man and the woman engaged in sexual activities that they both wanted indirectly predicted sexual aggression by reinforcing attitudes supportive of sexual coercion a recent metaanalysis of crosssectional and longitudinal data identified a small to moderate effect relationship between pornography use and sexual violence however individual characteristics and specific content have been found to moderate the strength of the association wright et al identified a larger effect among those who watched violent pornography the role of personality characteristics and peer pressure more recently researchers have begun to consider the link between pornography and sexual aggression within a wider context being influenced by a number of predisposing factors like hostile masculinity callousness delinquency and bullying behaviours these personality traits and individual differences have been suggested as a potentially more important predictor of sexual aggression than pornography use the confluence model an influential conceptualization within this field emphasises the importance of such traits for sexual violence perpetration personality traits are likely to influence individual behaviour more strongly than peers or pornography use a predisposition to sexual aggressiveness accounts for a greater part of variance in sexual aggression than pornography use several studies show that psychopathic traits including low empathy nonsexual delinquency and callousness are important factors in predicting future sexual aggression among adults ybarra and thompson found that low levels of empathy were more common among perpetrators than nonperpetrators of sexual violence delinquent behaviour is linked to increased odds of sexual harassment perpetration bullying which involves intentionally frightening causing distress or harm to another person has been shown to predict future sexual harassment perpetration which often precedes other types of sexual violence such antisocial behaviour is more commonly seen among adolescents who lack empathy findings from a number of international studies suggest that callous unemotional and nonempathic traits are related to aggressive behaviour in adolescents across cultures and that the capacity for interpersonal empathy is a protective factor against sexual violence perpetration callousness a key indicator of psychopathy is usually defined as the tendency to use others for personal gain without empathy or feeling bad about it callousness has been found to predict sexual aggression and delinquent behaviour in adolescent males it has been shown to contribute to aggression in two ways through reactive aggression which is a result of feeling threatened and proactive aggression the latter type of aggressiveness may be related to peer pressure andor striving for peer popularity peer pressure and peer conformity in general have been found to significantly predict sexual aggression among young men peer groups can influence the likelihood of sexually aggressive behaviour either by increasing pressure for peer group members to have sex or by increasing the acceptance of norms that justify forcing a women to have sex several studies have shown that conversations within male peer groups about current and hypothetical dating scenarios allow for young men to test and clarify their shared norms and also help them to acquire information about acceptable sexual behaviour current study the aim of this study was to provide robust and precise longitudinal insights about the often hypothesized link between pornography use and sexual aggression given the paucity of longitudinal explorations of the topic in adolescents and the related lack of insights about possible developmental aspects of the key association no specific hypotheses were formulated instead we focused on the following two research question is pornography use during middle to late adolescence related to male adolescents selfreported sexual aggressiveness and in the case the association is significant whether controlling for personality traits and characteristics that have been associated with sexual aggression affects its significance the relevance of this studys findings is highlighted by the recent increase in societal concerns regarding pornography use among young people as well as by the imperative to further improve sexual violence prevention programs in addition our insights may inform pornography literacy programs which have been recently proposed and developed to help adolescents in navigating the increasingly sexually explicit online environment method procedure classroombased selfadministered paper and pencil survey was used to collect data to maximize confidentiality large screens were placed on school desks to separate participants informed consent information was printed on the first questionnaire page but also delivered by a research assistant who visited all participating schools in addition contact information for a national youth psychological health centre was provided at the end of the questionnaire on average completion time was between 2025 minutes following national guidelines for ethical research in minors all parents were sent a leaflet with basic information about the research project prior to the study launch ethical research committee of the university of zagreb approved all study procedures measures selfreported sexual aggressiveness following ybarra et al at each study wave participants were asked how many times have they kissed touched or done anything sexual with another person when that person did not want you to do so timeframe for this general indicator of sexually aggressive behaviour was specified as ever at t1 and in the past 6 months at all subsequent waves a 3point scale was used to record responses to address the validity of this selfreported measure which had satisfactory testretest reliability we correlated sexual aggressiveness with social desirability at t2 and t4 the findings suggested that underreporting was unlikely substantial stability coefficients for the indicator ranged from 21 to 55 pornography use to assess the frequency of pornography use participants were asked the following question at each study wave how often have you used pornography during the last 6 months response options ranged from 1 not once to 8 several times a day the indicator had high stability across study waves age at first pornography useexposure was assessed by the following questions how old were you when you first saw accidentally or deliberately a pornographic video or movie four timeinvariant controls assessed at t2 included composite measures of bullying and delinquency as indicators of deviant behaviour as well as impulsiveness and callousnesswhich were treated as markers of possible psychopathy bullying was assessed by four items made a rude or nasty comment about someone on online social networks used the internet to embarrass someone threatened to hurt someone and shoved slapped or hit someone and a 4point scale for anchoring answers cronbachs α for the composite scale was 61 delinquency was indicated by four items adapted from ybarra mitchell and kjellgren et al again the 4point scale ranging from 1 never to 4 three of more times was used to record answers cronbachs α for the scale was 67 impulsiveness was measured with an adapted 8item version of the barratt impulsiveness scalebrief responses were collected on a 4item scale ranging from 1 never or rarely to 4 almost always or always the composite scale had acceptable internal consistency callousness was indicated by four items with the highest loadings on callousness factor from the adolescent inventory of callousunemotional traits response options ranged from 1 it does not relate to me at all to 5 it relates to me completely the aggregated scale had satisfactory internal consistency higher scores indicate higher callousness finally peer pressure and popularity which was assessed only at t1 was a composite indicator that included ten items adapted from the peer pressure and the peer popularity subscales of the the peer pressure popularity and conformity measure developed by santor messervey and kusumakar in a sample of early adolescents responses were recorded on a likerttype scale ranging from 1 does not relate to me at all to 5 relates to me completely the summed variable had good reliability higher scores denote higher peer conformism analytical strategy to distinguish between groups of individuals characterized by specific dynamics of selfreported sexual aggressiveness between approximately the ages of 16 and 18 years we used latent class growth modelling instead of treating all participants as sharing the same growth trajectory lcgm enables the estimation of parameters across unobserved subpopulations and the identification of two or more groups of individuals characterized by a distinct latent growth trajectory due to the fact that the population heterogeneity is unknown the number of subpopulations needs to be specified by the researcher thus a number of models with different number of latent classes are estimated and their fit and interpretability compared in the absence of commonly accepted procedures for choosing the model with correct number of latent classes we followed recent recommendations and used loglikelihood aic and bic values together with interpretability of groupspecific growth trajectories as the criteria for identifying the best fitting model the analyses were carried out using the lcmm package in r due to the fact that lcgm can converge to local minima each analysis was run multiple times with different starting values to increase the probability of reaching a global minimum all available study waves were used to estimate latent classes in sexual aggressiveness to assess change in male adolescents pornography use in the observed period we employed latent growth curve modelling a structural equation modelling approach that enables estimation of both betweenand withinindividual trajectories of change although pornography use was measured in all waves only data from t2t6 were used in lgm due to the fact that four of the five controls were assessed at t2 as recommended we first compared a linear and a nonspecified cumulative growth curves in pornography use the standard chisquare test indicated that the more parsimonious model should be retained it fit data equally well as the cumulative curve model next we explored an unconditional multigroup lg model of pornography with latent classes as groups to be compared finally a conditional model with the four control variables included was tested to assess lg models fit we inspected χ 2 cfi and rmsea statistics following tli and cfi values ≥ 95 and rmsea values ≤05 represented good fit to data lgcm was carried out using amos 24 statistical software package finally to address possible associations between latent classes of sexual aggressiveness and their pornography use over time we explored a multigroup lg model with latent classes as groups to control for potential confounders the multigroup assessment was carried out in a conditional lg model it should be noted that each of the selected controls is characterized by plausible mechanisms of contributing to both pornography use and sexual aggressiveness for example a participants delinquent behaviour may be an outcome of befriending normbreaking peers who are also more likely to use pornography and sexually coerce than other adolescents similarly striving for peer popularity might contribute to pornography use and sexual aggression if ones peer group is affirmative of both however to address concerns over potentially adverse effects of control variables on the estimation of key associations as well as dilemmas about whether some of the select controls could perhaps be outcomes rather than confounders the multigroup analysis was also carried out without controls after controlling for attrition less than 2 of information was missing in the variables of interest full information maximum likelihood estimation was used to deal with missing data results sexual aggressiveness latent classes the lcgm analysis compared models with the number of latent classes ranging from 1 to 6 the model with four latent classes displayed the best fit to the data its classification accuracy was high with posterior classification ranging from 92 to 99 the model distinguished among male adolescents who reported marginal levels of sexual aggressiveness which further decreased over time those characterized by no aggressiveness at baseline followed by a strong growth during the observed period adolescents who reported moderate sexual aggressiveness at baseline which then decreased over time and the final group of participants who reported stable moderate to high levels of sexual aggressiveness due to the fact that three of the four latent classes were small which presented substantial difficulties for multigroup latent growth analysis the two latent classes characterized by varying levels of sexual aggressiveness were collapsed into one to address the validity of this reduced 3class modelin which classes were relabelled into a b and c a set of oneway anovas were carried out with the key indicators explored in this study as dependent variable and latent classes membership as independent variable all personality characteristics differed significantly between the latent classes as expected mean values of bullying delinquency callousness impulsivity and peer pressurepopularity were the lowest in class a and the highest in class c after applying bonferroni adjustment for multiple comparisons mean differences in callousness and impulsivity ceased to be significant differences in the frequency of pornography use were significant only at baseline with the highest use reported by class b and the lowest use reported by class a figure 1 and table 1 about here sexual aggressiveness and pornography use unconditional 5wave lg curve model of male adolescents pornography use had excellent fit χ 2 2895 tli 985 cfi 986 rmsea 042 95 ci 020064 although no significant mean growth in pornography use was observed there was significant individual variation around it to warrant the models growth component next we tested a conditional model in which five individual characteristics were included as predictors of latent baseline and subsequent change in pornography use the model fit the data very well χ 2 5721 tli 965 cfi 981 rmsea 040 95 ci 025056 as presented in figure 2 only bullying and peer pressure and popularity significantly predicted baseline levels of pornography use more frequent bullying and higher peer pressure and popularity scores corresponded to higher pornography use none of the included characteristics significantly predicted change in pornography use over time table 2 and figure 2 about here finally to test the association between sexual aggressiveness and pornography use a multigroup lg curve model was carried out with classes as groups to control for possible confounding the conditional model was explored with structural paths leading from personality characteristics to latent intercept and slope in pornography use constrained to equality across groups due to the fact that the estimation failed to converge for the smallest group only the first two latent classes were compared the multigroup model has good fit to the data χ 2 12129 tli 942 cfi 964 rmsea 036 95 ci 025047 as presented in table 3 latent classes a and b differed in baseline levels of pornography useits frequency being higher in the group that reported higher albeit inconsistent sexual aggressiveness to explore if the difference is statistically significant we used a likelihood ratio test for nested models to compare the basic model with the one in which the mean intercept of pornography use was constrained to equality the comparison confirmed that the difference was substantial on average no significant change in pornography use over time was observed in either latent class omitting the control variables from the analysis affected the findings in that the average change in pornography use becoming statistically significant in both latent classes while pornography use slightly increased among male adolescents who reported marginal levels of or no sexual aggression in their peers who reported moderate and inconsistent levels of sexual aggression pornography use on average decreased over time this finding goes against the notion that pornography use contributed to participants sexual aggressiveness table 3 about here discussion almost 40 yearold concerns about the role of pornography use in sexual violence have recently been revived as a reaction to the unprecedented availability of online pornography the rising prevalence of pornography use among young peoplemost croatian men for example start watching pornography during adolescence prompted questions about the effects of pornography on sexual socialization including young peoples understanding of nonconsensual sex for many sexually aggressive traits also first manifest during adolescence yet the majority of research in this area focuses on the experiences of adults understanding the origins of a possible link between sexually explicit media consumption and sexual aggression can help to develop interventions aiming to inoculate young people against the acquisition of sexually aggressive scripts given the lack of longitudinal examinations of the link between adolescents pornography use and sexual aggressiveness the aim of our study was to analyse it using data from a 6wave panel sample of male croatian adolescents using lcg and conditional lg modelling two research questions were explored according to the findings the answer to the first questionis pornography use during middle to late adolescence associated with male adolescents selfreported sexual aggressivenessis dependent of whether the analysis is controlled for potential confounders with control variables included we observed no significant association between the change in pornography use and the pattern of sexual aggressiveness over time however there was a substantial difference in baseline frequency of pornography use between participants who reported little or no sexual aggressiveness and their peers who reported substantial sexual aggressiveness in the period under observation the former group was characterized by significantly lower initial levels of pornography use than the latter group with the controls omitted from the analysis we observed a significant change in pornography use over time in both latent classes while a slight increase was observed in adolescents who reported no or marginal levels of sexual aggression those who reported substantial although not consistent sexual aggressiveness were characterized by a decrease in the frequency of pornography use when considered together with the findings obtained with the controls included these results do not corroborate a positive dynamic association between male adolescents pornography use and sexual aggressiveness the answer to our second research question is more straightforward both of the key constructs were significantly associated with the selected personality characteristics the frequency of bullying and reported peer pressure and striving for peer popularity were significantly associated with both constructs an aggressive trait bullying seems to be logically connected to aggressive sexual behaviour studies have shown that bullying predicts sexual violence perpetration in some middle to late adolescent males it has also been shown that both sexual assault and bullying are dominanceoriented strategic behaviours young men who have internalised beliefs about hegemonic masculinity characterized by being powerful and dominant and who see aggression as a tool for social dominance may be more likely to respond with aggression to assert or prove their manhood the role of peer pressure and popularity points to the importance of male peer group dynamics for the understanding of both pornography use and sexual aggressiveness social contexts within a peer group around the acceptability of pornography and importance of sexual experiences may be one of the motivating factors for those who consume greater amounts of pornography or behave in a sexually aggressive way this may particularly be the case in early to middle adolescence a period in which the desire to be popular peaks friends attitudes and behaviour have regularly been identified as risk factors for sexual aggression among young men sexually aggressive young adult men report feeling more pressure to have sex than nonsexually aggressive men and are more likely to report greater peer acceptance of sexual aggression peer pressure is often enmeshed with peer selection because more aggressive adolescents will gravitate towards peers who hold more positive attitudes toward aggressiveness through shared experiences and group conformity these individuals may have their beliefs reinforced and behaviours rewarded vanden abeele and collaborators found that adolescent men who experienced greater perceived peer pressure and greater need to be popular with peers were also more likely to have pornographic content on their mobile phones what remains unstudied is whether more frequent pornography use also predicts higher peer popularity one of the ways in which pornography may facilitate greater peer acceptance is by projecting an image of hypermasculinity to male and female peers adolescent men who watch more pornography may also exhibit greater variety in knowledge of sexual practices a characteristic that has been found to be valued among males the association between baseline levels of pornography use and sexual aggressiveness was independent of the selected individual characteristics the observed link indicates that a relation between the two behaviours in an earlier developmental period during the transition from early to middle adolescence cannot be ruled out younger adolescents might be more susceptible to acquiring information about sex and applying it in their own lives than older adolescents early adolescence is particularly important in the context of youth sexual development because it is characterized by a rising interest in relationships and sexuality as well as by first experiences with pornography for example the latest national probabilitybased study of emerging croatian adults aged 1825 years found that the average age at first pornography use was 115 years among male and 135 years among female participants considering that most early adolescents have no sexual experience with another person pornographic imagery and scripting may be more influential in this developmental phase compared to middle or late adolescence in contrast to early adolescent boys older adolescents can weigh pornographic material against real sexual experiences based on appropriate conceptualization future studies should also address a possible moderating role of these constructs study strengths and limitations compared to the existing literature this study has several strengths including withinindividual longitudinal assessment of both key constructs a relatively lengthy observation period and wellpowered analyses in addition our analysis of the target association controlled for a number of potential confounders discussed in previous studies which adds credibility to our insights nevertheless the conclusions should be weighed against a couple of limitations first sexual aggressiveness was represented by a singleitem indicator although the item had reasonable construct validity and testretest reliability the fact that it covered a very broad range of coercive eroticsexual acts made impossible to explore developmental trajectories of sexual aggressiveness in the period of middle to late adolescence our decision to use a single item measure of pornography use is consistent with the literature suggesting that singleitem indicators should be used when the measured construct and its attributes are easily and uniformly understood this approach however raises questions around the content of pornography that our participants engaged with although it appears that violentaggressive pornography is not very common among adolescents important differences have been found between those who watch pornography depicting consensual and nonconsensual encounters future research should distinguish between consensual and nonconsensual sexually explicit content when addressing the link between young peoples pornography use and sexual aggressiveness a second limitation pertains to the fact that the most relevant group of participants for this studys topic was too small for meaningful multivariate analysis taking into account that this group is likely similarly slight in the respective population difficulties with statistical power behind estimations involving highly sexually aggressive adolescents will likely continue to hamper research in this area conclusions one of the few longitudinal studies that focused on possible linkage between pornography use and sexual aggressiveness in adolescence this study adds to the existing knowledge about this highly socially relevant topic taking into account the need to prevent or at least reduce sexual coercion among young people the significant association between pornography use and selfreported sexual aggressiveness at the age of 1617 years suggests that schoolbased sexual violence prevention programs should commence in an early developmental period and address among other things the potentially contributing role of pornography use in the development of sexual aggressiveness similarly our findings may inform recently proposed pornography literacy programs which were meant to provide tools for critical interpretation of sexually explicit imagery but also to educate that lack of consent is never acceptable and that healthy relationships do not feature coercion or violence pornography seems to play a complex role in contemporary adolescents lives and this calls for systematic research and educational interventions

the rising prevalence of online pornography use among mostly male adolescents revived social concerns regarding possible effects of pornography use on sexual aggressiveness given the paucity of longitudinal explorations of this link this study focused on the following two research questions q1 is pornography use during middle to late adolescence related to male adolescents selfreported sexual aggressiveness and q2 can personality traits and characteristics that have been associated with sexual aggression account for this presumed link using data from a 6wave panel sample of 594 male croatian highschool sophomore students m age at baseline 158 years sd 52 latent class and latent growth curve modelling were employed to answer these questions there was a significant baseline difference in the frequency of pornography use between participants who reported no or marginal levels of sexual aggressiveness during the period under observation 20 months and their peers who reported substantial sexual aggressiveness with the former reporting significantly lower initial levels of pornography use compared to the latter controlling for personality characteristics did not cancel this association in addition bullying and reported peer pressure significantly predicted initial levels of pornography use but not its subsequent change with the controls omitted from the analysis a slight average increase in pornography use was observed in the first latent class in contrast pornography use decreased somewhat among their peers who reported sexual aggressiveness insights from this study can contribute to schoolbased sexual violence prevention programs as well as inform recently proposed pornography literacy programs which aim to assist adolescents in navigating the increasingly sexually explicit online environment

introduction parkinsons disease a progressive neurodegenerative condition impacts the lives of those living with the condition and their loved ones in various areas of daily life the complex unpredictable and fluctuating nature of the condition means that people living with parkinsons disease must adapt and adjust every aspect of their lives continuously with needs that become increasingly complex to manage pwp rely heavily on support from care partners and various health care professionals it is not rare to see a variety of hcp be involved and consulted to support the management of the condition these may include medical specialists allied health professionals and other community resources while there is a clear need for multispecialty care in pd a sustainable model of multidisciplinary pd management is lacking 1 2 3 currently models of care have many drawbacks such as a lack of multidisciplinary collaboration a lack of access to care delivery at home or in the community and a failure to take the social needs of patients and families into account 4 5 6 7 to address these gaps the focus should be placed on codesigning a sustainable tailored and integrated care network with pwp using the actornetwork theory 89 we understand that the care for pwp takes place in a heterogeneous social network of human textual and material actors such as people technologies and resources that connect together with associations and alliances 1011 as such an integrated care network should leverage all necessary sectors in a coherent and effective manner to ensure patient care is tailored to the multidimensional needs of pwp 12 as highlighted in the world health organizations global strategy on peoplecentred and integrated health services integrated care considers various aspects of care delivery in a way that ensures people receive a continuum of health promotion disease prevention diagnosis treatment disease management rehabilitation and palliative care services at different levels and sites of care within the health system and according to their needs throughout the life course 13 considering that pwp must navigate through a continuum of care services that is always evolving integrated health services that combine a plethora of heterogeneous elements become a critical part of their journeys in addition the unique challenges faced by pwp emphasize the need for integrated care that can be personalized and malleable to evolving and changing needs over time to ensure this integrated care network is oriented towards the pwp there must be a coherent set of methods and models on the funding administrative organizational service delivery and clinical levels designed to create connectivity alignment and collaboration within and between the cure and care sectors 14 the design of such methods and models to optimize care for pwp necessitates a bottomup approach leading to concrete patientcentred solutions through a codesign approach patients experiences are at the centre of the design process 1516 for pwp this approach is extremely relevant as it gives them the opportunity to play a critical and pivotal role in envisioning solutions that meet their needs for an integrated care network as the main beneficiaries of this network pwp should be able to offer insights perspectives and experiences in its design the aim of this article is to provide a better understanding of experiences with health and medical services and to envision the integrated care delivery network from the perspective of pwp their cp and hcp we will present the results from participatory design workshops held in canada with pwp their cp and hcp in the context of the icarepd project the analysis of the workshops allowed us to identify limitations in the current care network where coordination of care relies heavily on patients we will also identify desires and requirements for a sustainable integrated care network that is personalized and meets the evolving needs of pwp the results of this study can inform the development of sustainable integrated care networks to better equip pwp to live fulfilling lives materials and methods context of the study the icarepd project in response to the complex situation faced by pwp a group of neurologists have developed the project on integrated parkinson care networks addressing complex care in parkinson disease in contemporary society 17 this multidisciplinary and international study uses a codesign approach to develop a homebased health care delivery model based on integrated care selfmanagement support and technologyenabled care 18 we used a codesign approach largely informed by the field of participatory design and experiencebased codesign where the patients perspective is seen as a central component to the design process 1920 our approach consisted of four linked steps that were coordinated among five countries preparation capture patients experiences by using narrative interviews and understand the patients trajectory design with patients cp and hcp scenarios for an integrated care delivery network and coproduce solutions by identifying key requirements for designing an integrated care network each country conducted the research activities and shared their results with the larger group for a final analysis care network each country conducted the research activities and shared their results with the larger group for a final analysis within the context of the icarepd project this article relates to the findings from the third phase the design scenarios part of the fourphased codesign approach in the spirit of patientcentred care patients as partners are invited in the early stages of the design process to share their experiences in managing their medical condition the aim of our codesign approach was not only to elicit contextual information or describe patient experiences but also to sustain the collaborative construction of new interpretations and enable various stakeholders to make sense together and coproduce knowledge 21 for this article we will be sharing the results from the canadian study specifically while the first two phases of the approach helped prepare the groundwork for the collective effort to capture patients and cp stories to identify care trajectories 2223 it is in this third phase that respondents participate in design workshops to help develop an improved model of integrated care at this stage of the research project each country developed a journey map and a table identifying main touchpoints key resources and technologies to support integrated care this step will then lead to the fourth and final stage which is coproducing solutions for implementing a tailored integrated care network in each country with recommendations as deliverables within the context of the icarepd project this article relates to the findings from the third phase the design scenarios part of the fourphased codesign approach in the spirit of patientcentred care patients as partners are invited in the early stages of the design process to share their experiences in managing their medical condition the aim of our codesign approach was not only to elicit contextual information or describe patient experiences but also to sustain the collaborative construction of new interpretations and enable various stakeholders to make sense together and coproduce knowledge 21 for this article we will be sharing the results from the canadian study specifically while the first two phases of the approach helped prepare the groundwork for the collective effort to capture patients and cp stories to identify care trajectories 2223 it is in this third phase that respondents participate in design workshops to help develop an improved model of integrated care at this stage of the research project each country developed a journey map and a table identifying main touchpoints key resources and technologies to support integrated care this step will then lead to the fourth and final stage which is coproducing solutions for implementing a tailored integrated care network in each country with recommendations as deliverables sampling purposive sampling was used to select participants for phase 3 design scenarios of the codesign approach sampling criteria were developed in collaboration with our tertiary pd centre to ensure adequate diversity in the sampling in terms of gender pd stage age and years since diagnosis the pd stage is determined mostly by motor symptoms and selfcare abilities on this scale 1 and 2 reflect earlystage pd 2 and 3 represent midstage pd and 4 and 5 represent advancedstage pd with respect to recruitment participants were approached by neurologists and pd staff in a hospital in canada the invitation to participate provided participants with information about the study and noted that participation would involve discussion among focus groups with a maximum of six participants per group participants were assured that their data would be treated confidentially and written and oral informed consent were obtained prior to data collection the study was approved by the research ethics boards at the ottawa hospital research institute and the university of ottawa data collection owing to the covid19 pandemic the participatory design workshops were conducted remotely between june and october 2021 the participants received by mail clear instructions and a package for a written exercise to be completed at home prior to the workshop participants had the option to complete the exercise alone or with the help of a cp for the workshop the participants also had the option to join on their own or with a cp preworkshop tasks for pwp and their cp prior to the workshops with pwp and cp the team provided participants with 2 activities which would later be used to guide the discussions the first activity a journey mapping exercise asked participants to describe their current experiences with health and medical services by identifying key touchpoints barriers and facilitators to accessing and using these services participants were provided with a journey map template including predefined event cards and emotion stickers ahead of the workshop they were asked to identify 2 or 3 major changes or events in their journey with pd and identify the key related touchpoints their experiences with that event and barriers and facilitators that have influenced their experience with that event they were asked to write that information in the journey map template so it could be used to guide their reflections during the workshop the second activity inspiration cards asked participants to create a scenario of their vision for an integrated care delivery model that puts pwp at the centre of care delivery again participants were provided with an inspiration card template along with a set of predefined cards from which they could select to include in their vision they were asked to select 3 or 4 cards for each of the categories identified in the template red cards were interaction cards to identify interactions with key people or services facilitating linkages green cards were resource cards to represent helpful resources to manage pd over time and black cards were technology cards for technologies to support at homecommunity models of care delivery workshop for pwp and their cp participants were invited to take part in an online 45min workshop in the form of a focus group to discuss their answers to the 2 activities that they completed at home for participants that could not attend the focus group sessions separate semistructured interviews were organized between the researchers and participants the purpose of the workshop was to determine pwps and cps priorities in terms of care delivery based at home or in the community from the perspective of pwp for activity 1 participants were asked to report with a higher level of detail on one or several of the events they have identified in their journey maps for activity 2 participants reported on and explained their selection for specific cards they had selected in their templates for the workshops that were held in a focus group participants were asked to share their insights for both activities on a rollcall basis to ensure all participants had the opportunity to speak preworkshop and workshop with hcp for hcp participating in the study activities 1 and 2 were similar to those of pwp and cp however for activity 1 hcp were asked to complete an online questionnaire which contained instructions for this selfguided component while no preworkshop tasks were assigned for activity 2 which would be completed as a group during the workshop to target and help define the preworkshop questionnaire for activity 1 participants were presented with two personas meaning two patient types within a targeted demographic disease stage attitude or behaviour the first persona represented a 59yearold woman who was recently diagnosed and experienced symptoms such as fatigue while working as an elementary school teacher the second persona was of a 78yearold man in a rural area living with an advanced stage of the disease while managing personal goals such as continuing physiotherapy through questionnaires hcp were asked to identify two or three changes or medicalsocial episodes that take place during the patient journey for both personas for each event in a personas patient journey hcp were also prompted to identify and describe key touchpoints helpful resources and barriers as well as emotions they think patients would be experiencing during the workshop hcp shared their answers to the online questionnaire with other participants for activity 2 the workshop moderator led the group to brainstorm about how they envision an integrated care model for pwp to facilitate the discussion an online collaborative platform displayed the series of red green and black inspiration cards participants discussed their thoughts and collaboratively selected inspiration cards based on the two personas as well as their own professional experiences data analysis prior to data analysis recordings from the workshops were transcribed verbatim and organized in the qualitative data analysis software thematic analysis was used to identify analyse and report on the patterns that were identified in the transcriptions of the workshops for activity 1journey map 24 as well as highlighted important events and envisions for integrated care networks in activity 2envisioning cards the anonymized transcripts were coded independently by two members of the research team using an inductivedeductive approach 25 as such the deductive reasoning was used by selecting core themes from the key concepts of the ant and supplementing the codes using an inductive reasoning where important moments were recognized in the transcripts and added to the predefined coding structure first anonymization of transcripts was done by assigning pseudonyms to participants p1p10 for patients cp1cp3 for cp and hcp1hcp5 for hcp and by removing any identifiable information within the transcripts subsequently two members of the research team reviewed the transcripts to code segments based on a predetermined coding structure inductive coding was used to identify new codes and consensus was obtained during a meeting with the research team for activity 1 the coding structure included 4 domains events touchpoints for each event barriers to making community linkages to using health care services or community resources and facilitators to making community linkages to using health care services or community resources for activity 2 the coding structure included 3 domains resources interactions and technology subsequently the research team created a mind map to better represent patterns visually for both activities this allowed the researchers to reach a higher level of abstraction and identify key themes of the participatory design workshops for both the journey map and visions for an integrated care network lastly the researchers conducted a final analysis for activity 2 using the key concepts of the actornetwork theory or ant 892627 this analysis allowed for a deeper understanding of the heterogeneous social network of actors that connect together to create an integrated care network 28 the ant is a sociological and anthropological approach used in organization and communication studies and its key concepts are used to understand how actor networks emerge how they are composed and constituted and how they are maintained over time concepts definitions actorsactants human or nonhuman entities that interact within networks of other actors actors could be individual or collective networks collection of actors that interact form and align with each other for the purposes of accomplishing actions or tasks intermediariesmediators an individual or object that serves as a connection between two actors translation translation consists in one particular actor being able to act as the spokesperson for the many others it manages to enroll in a particular program of action 29 the process of translation includes four stages problematization interessment enrollment mobilization of allies obligatory passage point a dominant actor that becomes a gatekeeper between other actors in the forming network inscriptions inscription is the process that ascribes meaning to artefacts inscriptions could be material elements such as documents but also practices rules routines or skills in our study we have used ant to examine the nature of the integrated care network and its components cocreated with pwp cp and hcp by studying the integrated care network as an actornetwork composed of a plethora of heterogeneous elements we can align support provided to pwp in their daily life by offering personalized and tailored care in the context of our study we explore the organization of local networks and their reconfiguration over time to support medical and social care at home for example they identified intermediaries or mediators who can form relationships between various actors to support care delivery at home results in this section the results are presented in two parts to highlight the main findings at the end of each activity first we describe the current experience of medical and social services from the perspective of pwp cp and hcp by identifying key events touchpoints barriers and facilitators second we present the key elements or components of an integrated care network coproduced by the participants during the workshop using the key concepts of the ant framework activity 1 exploring with pwp hcp the actual network of care the purpose of this activity was to create a map of patients journey from diagnosis to daily life with pd journey maps are used to depict the current experience of care models from the perspective of patients 3031 for activity 1 thematic analysis was used to identify themes and subthemes the main findings were summarized in a visual representation called the journey map the journey map provides a visual representation of the current state of care delivery in canada by identifying key events in the storyline of the pwp important touchpoints experiences and feelings and barriersfacilitators to making community linkages as well as to using health care services or community resources inscriptions inscription is the process that ascribes meaning to artefacts inscriptions could be material elements such as documents but also practices rules routines or skills in our study we have used ant to examine the nature of the integrated care network and its components cocreated with pwp cp and hcp by studying the integrated care network as an actornetwork composed of a plethora of heterogeneous elements we can align support provided to pwp in their daily life by offering personalized and tailored care in the context of our study we explore the organization of local networks and their reconfiguration over time to support medical and social care at home for example they identified intermediaries or mediators who can form relationships between various actors to support care delivery at home results in this section the results are presented in two parts to highlight the main findings at the end of each activity first we describe the current experience of medical and social services from the perspective of pwp cp and hcp by identifying key events touchpoints barriers and facilitators second we present the key elements or components of an integrated care network coproduced by the participants during the workshop using the key concepts of the ant framework activity 1 exploring with pwp hcp the actual network of care the purpose of this activity was to create a map of patients journey from diagnosis to daily life with pd journey maps are used to depict the current experience of care models from the perspective of patients 3031 for activity 1 thematic analysis was used to identify themes and subthemes the main findings were summarized in a visual representation called the journey map the journey map provides a visual representation of the current state of care delivery in canada by identifying key events in the storyline of the pwp important touchpoints experiences and feelings and barriersfacilitators to making community linkages as well as to using health care services or community resources thematic analysis revealed seven key events that represent significant changes either medically or socially for which they need support or access to medical or social services for each event participants identified barriers and facilitators to accessing care or resources process of diagnosis and diagnosis announcement for many patients diagnosis was found to be a key moment after waiting for a long period of time often patients knew ahead of diagnosis that something was wrong and that they should seek medical attention when navigating the health care system there seem to be mixed experiences with being able to access specialists and get referred to a specialized clinic some were able to get the attention from a specialist and a referral to a clinic rapidly while others had more difficulty doing so p5 well i think of course the main event was the diagnosis which was three years ago but i think i knew like i knew something was wrong before that i didnt know i had a lot of pain but i was almost relieved when i should say i just once i knew what the diagnosis was and i knew i would learn how to cope with it somehow for some people with greater difficulty accessing specialized care a key factor is related to their identity for women there seemed to be greater challenges in getting the pd diagnosis because they felt that they were not being heard when their first symptoms began their experiences were diminished and not acknowledged by some hcp p8 to get the diagnosis it took a while but i mean thats not i know its hard to diagnose parkinsons and because i dont have a family history for it because i was female i was young the typical symptoms i didnt fit everything and i think it was just my situation but also not being taken seriously by the two of the neurologists and thats a barrier but i think that like i said i think thats a lot of women in this country when diagnosis was reached by patients the process of obtaining it was facilitated by a key touchpoint the neurology clinics for patients that had access to those clinics they identified them as central to the diagnosis announcement patients felt like the care teams in the neurology clinics had the necessary knowledge and expertise to pose the diagnosis and provide support throughout that process p5 and i certainly have the great treatment and people looking after me for all my parkinsons symptoms so the touchpoints for me were of course the first touchpoint was the neurological clinic following diagnosis knowledge of the disease and clear directions and instructions on managing the disease are critical for pwp in canada this was identified as a clear barrier in their journey sometimes patients mentioned being left alone with no clear direction and instructions on what to do and where to go next this was also associated with feelings of anxiety and uncertainty for many p1 okay well i can tell you that i was not geared or pointed towards any community services or any information of any kind for parkinsons as a result pwp used a lot of their own channels to find information about pd for example patients mentioned joining information and support groups to get the necessary information others also mentioned using their own research skills to navigate the wealth of information they could find related to pd the endeavour of joining support groups and conducting their own research was mostly associated with positive experiences where they felt pride in being able to access information about pd p1 i finally found what i found by myself and i didnt find any support actually the support was very poor i have to admit with everything you hear on the news and anything else about the research and everything else about parkinsons p8 i believe that even when i go to the clinic you know youre just giv en a sheet saying this is the symptoms like theres no place to direct you and you have to do your homework on your own i am i dont know how other people find that but thats been my my experience p6 yeah then the same thing with the group that started that in winter and we joined the group there the parkinsons group and it was just tremendous and thats when we got most of our information because when he was diagnosed they just left us on our own and we were just you know with many obtaining knowledge and information from their personal networks and through their own means it pointed to clear gaps in terms of an organized and supportive network of information and resources unfortunately it is not all patients that were well surrounded and supported to obtain information some had limited personal support networks so for those that were more isolated the risk of facing greater inequalities in receiving supportive and quality followup increased following diagnosis the main supporting entity for pwp were family and friends they were seen as playing an essential role early on after diagnosis since they were helpful in looking for information and resources and for providing emotional support once more personal support networks were starred and seen as central for pwp to learn to live with their new diagnosis of pd p2 one thing i did do after the diagnosis but not too long after was going to a physiotherapist who was recommended by a friend of mine to do some well a series of exercises which shed be trained on however personal support networks have their limits and the need for formal guidance and support services is critical the lack thereof is problematic as it forces pwp to rely on their personal support networks for specific and complex guidance those with limited support in their personal lives may face greater social isolation and incomprehension on what to do following the pd diagnosis while there is a strong reliance on personal networks pwp also emphasize the role of general practitioners in supporting their diagnosis with pd general practitioners lack of expertise and knowledge about pd and the geriatric population more generally is a true impediment to serving those individuals in addition their limited communication with the pd care team limits their ability to have a role in this support function pwp feel that general practitioners are easily accessible and therefore wish that they would be better equipped to respond to their immediate needs or refer them to appropriate pieces of information or resources neurologists often had to fill in for the missed opportunities of general practitioners to care for their patients with pd hcp2 yeah i mean i think one of our main struggles is how we can be appealing for general practitioners to care for people with parkinsons thats a barrier but in a sense could be a facilitator but definitely i think both p5 and p1 you know we end up seeing ourselves being the gps of our patients which also shouldnt happen so how you strike this balance and make family doctors more at ease of managing problems that do happen lets say in the geriatric population but not necessarily specific of parkinsons and so in a way but they could also manage those problems for example thinking about the context of canada the role of general practitioners is essential in ensuring this kind of support for pwp and geriatric patients more specifically this role is amplified in rural and remote locations where specialists and neurologists may not always be present and accessible general practitioners serve to bridge the gap that may exist between people living in rural and remote locations and specialists therefore it is critical that they have appropriate knowledge and sufficient expertise in pd impact of pd on work life social activities and trips pd impacts many aspects of daily life for those that receive the pd diagnosis one major area that is impacted is peoples professional lives patients expressed that they were conscious that their disease would have an impact on their professional and social lives and that they would have to adapt to their new reality the difficult part for many was that they would have to deal with those changes on their own and receive little to no support in this transition for some this change happened at a moment when they were not expecting it leaving them with negative experiences or having to find adaptations on their own these fears were expressed by both cp and pwp themselves hcp2 i think i mentioned what would happen if she would change schools for example and she would practice without a place that was one aspect and then um sure im you want to talk about barriers facilitators but that was something that occurred to me in terms of a teacher that could all of a sudden have to teach in another school another place and so how that would change her care that was one p3 the idea is i ended up stopping working voluntarily because i was losing power on one side and i was doing physical work before somebody gets hurt i decided to take myself out of the job knowing that changes in the professional realm would occur pwp need to have access to resources to information to help them better understand the disease and to better comprehend the impacts it may have on their professional careers help is needed to allow pwp move beyond the acceptance of changes in their professional lives to the understanding that adaptations are possible to help them continue to live meaningful professional lives p5 i think you know people faced with early on in their parkinsons they wanna just you know they the initial reaction i think a lot of people have is just keep plugging away and keep everything as normal as possible but is that really in their best interest but helping them work through that problem theres definitely a lack of resources i think to help them work through that specific issue hcp also reflect on this issue by acknowledging the need to investigate deeper into explanations for certain symptoms to support pwp to continue with their active lives longer hcp4 one of the things im truly interested in if shes very young she has a fulltime job very demanding in elementary school so for me education really with respect to why is she having such terrible fatigue because we really want to happen to her with how young she is is to keep her active and keep her functioning higher for longer so for me education is really key with understanding what is going on in the sleep whats going on with fatigue can we better manage that to actually address potential issues as well when people arent sleeping well and that increases their risk for having you know other problems and that emotional field so for me its the education on that level is where i would like to see some input this educational component was important professionally for pwp but also in all aspects of their lives they have indicated that being proactive was identified as a facilitator to overcoming challenges and transitions in their journey with pd however fragmentation of community services remains problematic and was identified as a major barrier for pwp in fact much of the responsibility to identify the resources available is left in the hands of patients some have the energy and capabilities to identify the resources available to them but this may not be feasible for others this can unfortunately widen the inequalities in access to care depending on patients circumstances thinking about social determinants of health several contextual and identity factors may intersect to amplify these inequities that exist between the diverse pwp cp specifically spoke about the need to have increased direction on available community services for pwp cp3 yeah and to be honest p3 isnt at a point with the illness where weve done much in this along these lines but i would imagine that it would be great if there was a focal point somewhere and you can go and you can ask well what physiotherapy practices in name of city specialized in we found that out through word of mouth what about speech i dont know if some parkinsons patients that want to access speech patho or speech therapist massage therapist like its all at least it has been for us and maybe we havent found the key yet the keyhole in the door but as we try to find those supports we kind of starting all over all the time and we ask a friend like a physio who do you know that has specialized in parkinsons and then you go to the physio you and what about massage therapy and who do you know p2 nods its just not as connected as it should be in my view treatment plan or changes in the treatment throughout the journey with pd an adequate treatment plan is important to allow pwp to continue with their daily activities ensuring that a treatment plan is effective and ensuring a reduction of symptoms are just two examples of things that can give hope to pwp to continue living with a certain level of quality of life medication specifically was mentioned by patients as being a significant event in their journeys in this regard communication with the medical team on treatment is vital and seen as a facilitating factor patients noted that treatment plans need to take a personalized approach to ensure that their needs are addressed p7 oh i think the first one would have been appropriate medication and treatment for my parkinsons symptoms which made a huge difference i was able to do more physical and social activities once i got on the medication i kind of didnt want to do it for quite some time i thought i could manage it myself but it just came to a point where i realized that i did need some extra help so that made a huge difference for me treatment plans that include home supports were valued by many patients and hcp however there was a consensus that home supports were constrained by financial burdens the provision of community supports was said to be financially demanding for community organizations while equipment to promote independent living were considered monetarily out of reach for pwp living in the community hcp survey response lhin local health integration network is limited in what they can provide due to budget cuts and cant offer the home health support they would benefit from the cost of equipment in the home is high and they may not be able to afford all that is suggested to them to improve quality of life and prevent falls as pwp are learning to live with their condition treatment plans and adaptations to treatment plans make a huge difference in their ability to have a good quality of life while attentive communication with the health care team is essential barriers to financing can impede the successful delivery of effective supports onoff episodes or communication challenges another significant event in the journey with pd is adapting to changes and episodic symptoms patients discussed their issues with communication for example which impacts their daily activities and social lives some of these episodic symptoms and changes to their capabilities necessitate support and help which are often very hard for them to find this is especially hard when they require specialized help as was mentioned previously access to help can be challenging for many accessing the right people but also accessing the support in a timely fashion can be very difficult this can have devastating consequences and negatively impact pwps ability to have a good quality of life patients also brought our attention to a lack of expertise from hcp like physiotherapists among others this challenge is amplified for pwp living in rural or remote locations well documented is the limited capacity for rural remote and smaller locations in canada to host specialized medical services virtual consultations have been suggested to counteract this gap for those regions p5 one of the barriers that immediately comes up is smalltown canada and how people in canada access specialized services so i think that really that unfortunately in a lot of places thats just not possible because there arent any specialized services in the smaller towns and especially if youre thinking about you know physiotherapy or those types of things where the local physiotherapist might not have seen very many parkinsons patients but i think that the idea that maybe the most practical for them is to try to access local whatever the resources are locally even if theyre not super specialized access to staff with pd expertise in the community was identified as a barrier by pwp services developed specifically for people with pd such as physiotherapy exercise programs or speech therapy led by allied health professionals with expertise in pd were identified as rare in the community telehealth such as virtual consultations have been suggested by some participants to overcome this shortage of expertise this solution would be appropriate and fit with the geographic specificities in canada stronger symptoms access to home care or medical equipment the challenges amplify as pwp experience stronger symptoms over time in preparation for this transition patients expressed their outlook in anticipating their future needs as they began looking into community resources for the required support particularly both cp and pwp themselves were beginning to plan for home care support services many of them shared a desire to be accompanied in the planning of progressive pd care such as being provided with the necessary medical equipment they explained they needed to be guided as they searched and selected resources within the community in anticipation of the impact of pd on daily life in addition hcp also recognized this need for pwp to be guided when navigating the health care system p3 specifically here is to start thinking about an assisted livinglike situation how long are they going to be in their home how long are they going to be able to negotiate stairs etc so with falls or near falls that have happened theres only so much that we can do with this impaired balance and somebody whos had parkinsons for a long time so i think its really important to start thinking about this and yes we can organize mediated help at home similarly pwp shared their expectations with respect to having access to resources within the community that can support and guide them in their journey with pd gaining access to community resources was once again left in the hands of pwp where they had to reach out on their own and find the appropriate support in their community p1 so the example that i used beforehand was contacting the local name of resource centre to get a caseworker involved and to do a home assessment to assess the needs in the home and provide access to local resources have an ot occupational therapy assessment come in put things in you know like grab bars assess the needs in the home prevent falls link them to local resources in name of rural area since they live an hour away from name of urban centre so were not quite as aware of them that was the example i used for the life event with the name of resource centre as mentioned previously participants mentioned the need to have resources for cp as well this aspect was raised by cp pwp and hcp who recognized the importance of ensuring adequate access to supports for cp due to their role being viewed as critical all participants agreed that their wellbeing was also important hcp1 so community resources would be having some home care coming in using respite if needed so you dont have that caregiver fatigue for his wife as theyre elderly and then what was the other part sorry i cant see the fullso the respite the home care any extra means that they might need in name of rural area like the name of food delivery service and sometimes the name of resource centre is more aware of those local things than we are in name of urban centre in many instances patients explained that when symptoms progressed and became more present in their daily life they felt little support and faced several barriers including financial structural and organizational barriers financial barriers specifically include the cost of therapies medications and supplies as well as the rising cost of these elements as part of a patients pd progression in canada even though health care is provided through a publicly funded health care system some specialized and privately managed services are not covered and would entail outofpocket expenses if patients do not have a complementary health care plan this was often a source of stress and anxiety for many participants p3 lowcost physiotherapists especially you know they charge a higher rate than normal therapy which is fair enough with a specialist but its certainly a barrier for some well i think i put down domestic support as a segue into issues of affordability for a lot of those supports hcp1 they contact the name of health care service to get some supports in the home name of health care service is limited in what they can provide due to budget cuts and cant offer the home health support they would benefit fromthe cost of equipment in the home is high and they may not be able to afford all that is suggested to them to improve qol and prevent falls barriers to accessing transportation services were also expressed as mentioned previously this challenge is amplified for pwp living in more rural or remote locations in some cases participants even anticipated the challenges that would arise with transportation services as they progressed in the pd journey p1 at this moment i do not have problems with transportation like i still drive i am steady enough for that but eventually thats not gonna work it was noted that during these tiring periods when symptoms became stronger social workers were mentioned for their important facilitator role in helping and supporting pwp in their care p3 i would love to have a social worker be at hand that can help guide them in the right direction p5 remembers the period where we had a social worker in the clinic that was just a godsend with huntingtons people or difficult cases we would pick up the phone and they would an hour later theyd be connected with our patient it was just awesome it should be the way it should be so that we dont have to do the work but we can direct people and hook them up with social workers or other facilitators hospitalization episodes and rehabilitation time it is not uncommon for pwp to require additional support via hospitalization in fact some participants including cp discussed the value in receiving hospital care when needed cp6 thats the thing if we hadnt been at the hospital we would not have had all of those its just because thats the hospital that organized it because they didnt want him to go home but they wanted him to go to a special place for rehabilitation interviewer ah okay i understand so thats why they organized it i dont think it would have been organized for just parkinsons but i dont know im not sure maybe yes maybe no i dont know but they were very helpful journey with pd the visual representation of the journey map allows us to see that several networks of actors are identified by the participants during the care pathway of pwp and these networks evolve over time by enrolling various actors the journey map carried out with patients cp and hcp allows us to identify the key actors who are at the centre of the network and how their enrolment in the network evolves over the course of the care pathway and identify the barriers and facilitators that are shared by the participants in activity 1 the existing care network is unresponsive fragmented and it is difficult for pwp to find the resources necessary to maintain their quality of life for canada participants draw our attention to the accessibility of services in the community and the coordination of care for example all the patients express the need to identify available resources specialized in pd in their community on the other hand some patients expressed the fact that having access to mediators greatly facilitated their journey and helped them identify resources in their community such as physiotherapists and occupational therapists various distributed local networks enrolled over time some local networks are constituted over time to support pwp over their care pathway for example at the time of diagnosis the personal network and care network are identified as key touchpoints by the participants but later the community network is important we can see that the experience of pwp is rather negative during three events at the time of diagnosis when the symptoms and the disease progress and when pwp need more support at home and when they need to buy equipment or to arrange their environment these are three events in the lives of patients where access to medical and social services is considered more problematic diagnostic process onoff episodes and communication challenges and stronger symptoms home care and medical equipment all patients wish to be guided oriented and would like to have systematic access to a person contact or a single point of contact who will help them when their disease evolves another important element highlighted by the participants is the role played by patient organizations in canada patient associations are very active and offer various resources for patients and cp by organizing webinars conferences or offering support groups however the analysis of the journey map shows us that the current network is very medically oriented forgetting the social needs of patients a medically oriented care network in its current form the current care network is highly focused on medical onboarding of pwp as such there is a strong focus on immediate medical needs such as symptom treatment and medication still a broader holistic onboarding is needed to account for the impacts of pd on all spheres of daily life participants mentioned the desire for medicaloriented care but also support in other aspects of life which are impacted by pd p3 this may be a little bit of a danger focusing too much on the parkinsons side and i mean theres lots of people who need home care or some kind of home care for you know for the whole alzheimers issue for example i mean there are worse things supposed to happen with parkinsons so i guess you want to separate out what you want the specialized for the parkinsons and whats much more generic should be existing the organization of community services varies considerably and it is hard for patients and caregivers to navigate through this web of care pwp try to connect all the actors services involved in the web of care due to the lack of care coordination or clear community linkages this work done by patients and their families reduces their ability to manage their social and medical needs effectively maintain independence and qol 3 the analysis of activity 1 shows us is that the current care network is fragmented and distributed over several networks of actors who are not always connected to each other or who do not communicate easily activity 2 envisioning integrated care delivery the scenario created by the participants during the workshops present how pwp imagine an integrated care network based on at home and community models of care delivery based on the scenario created by the participants and the thematic analysis of the discussions we have identified key components for designing at home and community model of care delivery in canada we guided our analysis using the key concepts of ant and our objective was to identify the key components of the integrated care network there are three main networks that must be connected to each other personal network care network and community network within each network there are key actors or actants that could play fundamental roles such as improving communication offering emotional support providing tailored and personalized advice or playing the role of mediators the personal network includes not only family members but also specialized or support groups for pwp the purpose is not just about meeting pwps medical needs but about staying active and finding specialized resources within their network to maintain social activities a lot of pwp consider the importance of joining a support group in the local patient association to create a network around them pwp would like to use this network to discuss ideas with people in a similar situation or to share social activities p3 what would be attractive to me would be some combination of support group and activity i never became involved but ive got a friend that does in name of city there was some group and they do boxing and dancing the personal network includes not only family members but also specialized or support groups for pwp the purpose is not just about meeting pwps medical needs but about staying active and finding specialized resources within their network to maintain social activities a lot of pwp consider the importance of joining a support group in the local patient association to create a network around them pwp would like to use this network to discuss ideas with people in a similar situation or to share social activities p3 what would be attractive to me would be some combination of support group and activity i never became involved but ive got a friend that does in name of city there was some group and they do boxing and dancing p2 dancing yes p3 its mainly people with parkinsons but not just people with parkinsons so its just not a support group where people sit in a circle and talk about their problems cp3 p2 and p1 chuckle it brings people together in an activity and then people are informally going to say geez my medication isnt working well this week or something else p2 yeah my family doctor has recommended that i go to that dance group family doctors or pharmacists could play an important role in the future integrated care network especially for people living in rural or remote locations for example the family doctor could be a facilitator and for some patients may also be a resource to help them receive specialized and personalized care such as access to massage therapy or psychological followup on the other hand for geriatric patients this role will be more and more important when the disease evolves and the need for home care increases family doctors or pharmacists could play an important role in the future integrated care network especially for people living in rural or remote locations for example the family doctor could be a facilitator and for some patients may also be a resource to help them receive specialized and personalized care such as access to massage therapy or psychological followup on the other hand for geriatric patients this role will be more and more important when the disease evolves and the need for home care increases cp3 i think one of our main struggles is how you know we can be appealing for general practitioners to care for people with parkinsons thats a barrier but in a sense a potential could be a facilitator but definitely also a challenge because gps do seeactually i think we have that feedback already with the icarepd project that gps see a whole gamut of patients and pd alerts are our main focus of practice its a grain of sand in their ocean of patients chuckles but definitely i think both p5 and p1 you know we end up seeing ourselves being the gps of our patients which also shouldnt happen so how you strike this balance and make family doctors more at ease of managing problems that do happen lets say in the geriatric population but not necessarily specific of parkinsons and so in a way but they could also manage those problems for example cp5 so i guess maybe one of the keys as p3 was saying not every patient was saying not every patient needs all of these services but i do think if you look at our red boxes every patient with parkinsons i feel an essential need is a general practitioner for many patients in smaller communities thats still unfortunately easier said than done but i think thats critical this is not a condition that is going to get better and is going to get worse and we know all the nonmotor things definitely having the family doctor involved early and feeling more comfortable and knowing the patient can really make a big difference to how the patients are doing because of you know treating their depression and really having a really strong family doctor can be a real key and again i think with our canadian health care system is something we need to make sure is a real part of this process patients believe that some technologies will play an increasingly important role in the future and will be key actors in the personal network these technologies will provide access to online resources but also serve as a communication tool with the care team to maintain proximal communication moreover access to these technologies can allow people living in rural areas to benefit from online services and thus reduce certain inequalities of access that some people living far from large urban centres may encounter p4 so for me virtual reality has opened up access to expertise and you know having resources that you wouldnt typically have for me that would be a big bonus although saying that i live in name of rural area and cant do virtual reality from my house since we have terrible wifi reception so it opens up in that avenue but if you have terrible wifi then theres a limitation and a barrier to that p5 how am i ever going to know whos the physiotherapist thats within five kilometres of our patient who lives in a small town somewhere in canada theres just zero chance i know that and then who is going to help us figure that out and i think this is where technology is the only solution even in name of city we cant keep a running database of all the physiotherapists let alone the social workers let alone the occupational therapists so i think we have to engage technology to help us come up with solutions for this because for 1520 years ive tried to keep a list of these types of things and it doesnt work opp single point of contact and navigation tools two components are identified as opp ie as central actors that will contribute to the creation of the integrated care network its personalization and maintenance over time so these are critical network channels and fundamental components of an integrated care network a single point of contact a person connected to the neurology clinic is an essential element to bring different actors into the network in order to personalize the medical and social care offered to patients p7 having the ability to contact someone to get some information if im not able to find it myself hcp3 i think a wonderful model would be if theres a nurse coordinator who interacts with the patient and she identifies four things that should be done education physiotherapy maybe day programs or whatever so she fills out four forms for pharmacy optimization of drugs another key element of the network is a resource browser which could take different forms such as icare resource finder as suggested by one participant this is a tool that could be shared and accessible to both health care professionals involved in the network and pwp hcp2 is key you know building this network of resources by having ways to obtain that information in a certain geographical area but i would say name of rural area would be one and its not that far from urban centre and we receive patients from that area and of course the challenge is not only how we identify them but actually maintain that tiein so icare finder resource that allow us to help these patients navigate whatever resources are available and so i guess thats one potential facilitator but its definitely challenging but then the likelihood of having resources in rural area i think its less at least not in terms of the sheer number but also that the degree of expertise in parkinsons disease for example key intermediaries or mediators specialized nurse advisory board information brokers programs orientation specific ehealth technologies improving communication with hcp the future integrated care model must be a model of care that relies on a close relationship with a specialized nurse because interpersonal communication is central for pwp this is the basis of a humane model of care and allows for personalized management throughout the course of the disease it is therefore essential to pay attention to the role played by the nurse as an important intermediary or mediator within the network the specialized nurse will act as an intermediary or mediator between the different networks identified they are responsible for coordinating care by being a key player in the care network developing personalized educational resources for pwp but also for helping patients navigate the network by identifying tailored resources in the community network to do this specialized nurses will need to be trained and equipped to maintain close communication with patients and their families p2 it might become an oldfashioned idea but i do think patients they really cherish the physical patientphysician relationship a lot could change but definitely having these direct interactions i think its very important cp4 so for me i would like to see the nurse coordinator as p1 is saying to then spread out and bring out a multidisciplinary team on board depending on where that person is on their journey ive been working for a while and a lot of times the nurse coordinator was a team coordinator that would link up with the other professionals in a said team and whatever that team is right so thats looking probably at health care in the past where you had a team part of a movement disorder clinic whether thats inperson or virtual p2 i think a lot of it has already been said but perhaps i like the idea of the curation of how can we help the patient navigate in the wealth of information and i do agree that information is key but it can also be toxic in a way and so whats the role of we health care professionals in helping to navigate that wealth of information to keep the integrated care network adapted to the needs of the patients and their families pwp propose an organizational structure involving a patient advisory board that would allow an evaluation and adaptation of the network over the years this could aid in assessing and improving its effectiveness p2 i think the idea we had that idea when we created the advisory board for the name of network but of course that could be expanded in almost like a forum or you know create times where you can actually brainstorm with patients and cp of how they seek care right and so what p3 is saying expanding this idea of a patient advocate or a patient advisory board right and but be part of on a regular i guess be part of the structure of the care delivery model right where theres a more regular interaction with patients and cp patients draw our attention to the importance of not centralizing the network in large urban centres but adapting it to people living in rural areas who may not have access to transportation services thus patients suggest identifying facilitators or information brokers within the community this role could be assumed by a social worker who is familiar with community resources and who could be a point of contact for patients and their families an important resource within the integrated care network is the creation of tailored programs for orientation that address specific needs of pwp for example patients suggest that a program could be developed to support patients and cp through the various patient trajectories for example a program could be tailored and personalized for newly diagnosed patients to help them understand their disease and address their specific needs as well as for patients whose disease is progressing and who need to anticipate their future needs such as home care these programs are not only for individual patients but also for their caregivers it is therefore a collaborative approach that is favoured by the patients pd is a disease that has an impact on family and social life therefore offering and designing specialized programs are important components of the integrated care network indeed integration also involves the family and a better integration of the personal network of people living with the disease cp3 and whether its a spouse or its another care somebody who is stepping up to play a role like a child an adult child or yes obviously i think our the support support system or ideal care system should include you know a family orientation if a family if thats what the you know the individuals choose for patients specific ehealth technologies will have a role to play in the future and will be important intermediaries to facilitate the coordination of care but also communication with the care team unlike the technologies mentioned as key actors within the personal network these technologies mentioned here will play a very specific role in facilitating communication and care coordination they will therefore play a more important intermediary and mediation role within the care network the possibility of having a help line or online consultations is an important component of the network in the future however the current network needs to restructure itself to be able to offer this service which also requires human resources and infrastructure p3 i just find telephone communication is not effective there has to be another way and i think virtual interactions which is then difficult to organize because there has to be a booking there has to be a zoom link you have to be online and that in itself take a lot of time of admin people or doctors or nurses i have absolutely no idea how to solve this the better we are in helping people with an integrated care approach its so time and resource consuming i dont have anything productive to add is what im trying to say p1 so in terms of technology i would say that telemedicine has been really good at having easier access to the physicians to get advice and just those virtual appointments have been really nice especially for those was trouble with mobility or access to rides to get to appointments and stuff i think virtual appointments have been really good for patients p2 i find that now with my chart at the city hospital anyway you can go in and look at your test results and things like that if you understand what it means so i will go in there and look at reports and some things i had to fill out for various doctors i also have the telehealth and mobile applications so i just find any technology the more technology you can have you know what it means its useful to have at times inscriptions the creation and use of various forms of inscriptions by the integrated care network contribute to better defining care pathways in personalized ways shared assessment tools that will allow the care team to define with the patient and his family a personalized care pathway and support an informed decision will have to be created and shared hcp3 the integration of the nurses and the physicians assessment which services should be utilized accessed and at that time put in place and so you know i think because this so much depends on the individual and on the family right so you dont have one model that fits everybody but you have the option of a whole list and menu and you pick and the nurses perspective and the doctors perspective and the patient and his familys perspective cross off these overlapping needs or the needs that have been collectively identified that would be the bestcase scenario for me to access the resources available at the heart of the future integrated care network are tailored educational resources that address the needs of different patients trajectories trajectories that we have identified in the early phases of the codesign process 22 these educational resources will play an essential role in supporting the selfcare process throughout the patient journey p4 education for me is a huge thing and one of the big areas of focus that i would like to see is more along the lines of chronic disease selfmanagement programs that stanford have piloted done with educational workshops for those in major diseases but certainly some aspect of understanding chronic disease selfmanagement program and whether thats through as p5 and p2 said the name of the organization or through name of the organization or linking up with experts from your movement disorder clinic but for me that would be a big role that i would like to see one element to consider in the development of an integrated care network is the role that ehealth technologies may play in the future for example some technologies such as sensors or wearable devices that collect data in real time and generate big data will contribute to improving the personalization of medical care p2 i think the wearables although they have a lot of potential were still trying to understand exactly what we use it for even just measuring parkinsons disease and its different dimensions and then of course the next step how can we use it for care so i think that will really take longer it will be a longer process but is still valuable right if ideally we could technology could help us to understand whats happening to people living with parkinsons between you know clinical visits that will be huge but i again i dont think youre interested in getting the big data 20 pages of a report but in an eloquent synthetic way can technology gives us a portrait of how a snapshot of how the patient has been doing in the six months prior to seeing them in person the ant analysis allowed us to identify key components within the network of care designed by the participants in canada the integrated care network designed by the participants is composed of three interconnected networks where key components play an important role to support personalized care in pd the integrated care network codesigned by the participants must be constituted made and remade over time to evolve with the patient trajectories discussion as mentioned previously the analysis of activity 1 illustrates a current care network that is fragmented and distributed over several networks this main problem was recognized by pwp who shared their experiences in navigating a system composed of mediators and intermediaries as actors who are not always connected to each other or who do not communicate easily such a research project is valuable in addressing gaps and proposing solutions to lead to an integrated care network that is truly based on patients needs to optimize and personalize the care for pwp we need an integrated care network that is tailored to patients needs with three core components opp mediators or intermediaries and inscriptions we discuss each of the three core components followed by a discussion on their relevance and practical implications to support personalized care for pd opp as boundary spanners to enroll actors opp refers to an important point of contact that channels all interests into one direction 9 the first stage of the constitution of the network around the patient involves key actors identifying the needs and interests of pwp this actor could be human or nonhuman and becomes the opp making themselves indispensable within the integrated care network in our study specialized nurses are the focal actors in the integrated care network as part of their work assessment tools can be used to identify patients needs and build a partnership with the patient their family and other actors in the community their role therefore promotes shared decisionmaking and contribute to personalizing the care pathway our findings align with recent literature on the role of specialized nurses as facilitators with expert skills within integrated care networks 2 32 a single point of contact and navigation tools are indispensable for the constitution of an integrated care network and the stabilization of the network over time by supporting a system of navigation and alliances inside the network 8 the roleplaying by the opp is fundamental for exploring how other actors within the network are enrolled progressively intermediaries to connect actors in the networks at the heart of the network there are intermediaries or mediators who will play an important role in promoting communication and information exchange there are four important intermediaries specialized nurse advisory board programs orientation and specific ehealth technologies for improving communication between care team and patient these technologies will improve communication with the care team and facilitate the exchange of information they will therefore play a very specific role and will be part of an informational and technological infrastructure that must be put in place to allow for more patientcentred care within the personal network two intermediaries are identified as being able to play an important role in the constitution of a personal network that will play an important support role in daily life first the implementation of a program designed for the family at the time of diagnosis and as the disease progresses could allow the patient and his or her caregivers to find both emotional support and information resources that will allow them to better understand the disease and anticipate future needs this aligns with previous research that emphasizes the importance of supporting the family structure which is especially helpful for cp in that it aids in reducing caregiver strain 33 other research also reflects on the importance of providing caregiver assistance and support 3435 which aligns with our findings that indicate the need for familyoriented approaches within the community the envisioned program could be designed and organized in collaboration with the neurology clinic and parkinson canada which is a patient organization well established in canada and offering services in both official languages this program could offer seminars for newly diagnosed patients and their families or specific information sessions for families as the disease progresses and new social and medical care needs emerge the objective of this program is to offer highly targeted resources at key moments in the patients trajectory ie at the time of diagnosis and when symptoms progress and pwps need to be better informed and accompanied to find resources within the community network another important intermediary that connects networks is what we call information brokers these facilitators can be different actors within the network depending on the needs of the patient for those living in rural and remote locations several options have been described in the literature as viable and facilitating access to care and health information 36 for example advances in virtual care through telemedicine or nurseled clinics are opportunities that allow patients and families to receive support even when they live in more rural and remote locations 36 for some patients who have a good relationship with their general practitioner they could take on this information broker role recent literature describes the role of general practitioners as pivotal in the care for pd 37 these hcp have access to various tools guidelines and benefit from proximity with patients which allows them to make recommendations and suggestions that can improve the wellbeing and quality of life of patients and their families throughout their patients journey with pd 37 for other patients who have a more complex disease trajectory and require more resources in the community a social worker could be that facilitator it will therefore be up to the care team to identify with the patient and their cp the actor within the community network who can assume the role of facilitator or information broker this could be the general practitioner the social worker or other allied health professionals inscriptions to support tailored care network and improve communication process inscriptions is a process in which the translation of actor interests is embodied in artefacts such as texts technical objects embodied skills and management tools 9 any component of the heterogeneous network could support the constitution of a social order and may be the material for inscriptions the stability and social order according to ant are continually negotiated as a social process of aligning interests inscriptions represent interests inscribed into an artefact or a tool as law 8 points out thus a good ordering strategy is to embody a set of relations in durable materials consequently a relatively stable network is one embodied in and performed by a range of durable materials as identified in figure 2 several inscriptions were identified by participants as key components of the integrated care network the actors present in the different networks may have diverse interests however the stability of the network depends essentially on the ability to translate ie to reinterpret the interests of others into ones own this work of translating the interests of others presupposes tools programs such as assessment tools programs or resources that will support this process of translating interests and needs this will then be embodied in texts tools which become the support of this work accomplished by the actors together to create and maintain the network these inscriptions coproduced and shared are also communication tools that will circulate within the network and support the coordination work practical implications in support of recent literature on the value of outpatient integrated models of care 5 our study helps delineating key components of integrated care networks for each component we have identified management tools skills or educational resources that could be created or used in the future by this integrated care network thus the codesign workshops allowed us to generate concrete and practical solutions that will be discussed in the final codesign phase with the different stakeholders of the icarepd project to improve person centredness tailor and personalize care and propose a holistic approach of pd in integrated care three design features have become relevant identify boundary spanners select mediators and create informational and technological infrastructure and produce and share tools data and resources each of the design features involves various practical solutions that could be useful to develop and implement an integrated care network that considers the three main patient trajectories identified during the initial phase of the codesign approach the practical solutions suggested are drawn either from the scientific literature or from suggestions ideas made by the participants during the codesign workshops we discuss a few examples suggested in figure 4 ture and produce and share tools data and resources each of the design features i volves various practical solutions that could be useful to develop and implement an int grated care network that considers the three main patient trajectories identified durin the initial phase of the codesign approach the practical solutions suggested are draw either from the scientific literature or from suggestions ideas made by the participan during the codesign workshops we discuss a few examples suggested in figure 4 examples of boundary spanners single point of contact it could be a service centre that provides a singleentry point to access specialized care team for canada the service centre involves a specialized and trained nurses coordinator who will play the crucial role of boundary spanners 38 navigation tools these tools could take many forms and be adapted to the local and geographical reality a key aspect of supported selfcare includes the enabling of pwp to connect with ongoing personal and community networks as part of the icarepd project in canada one suggestion could be to develop various tools to support navigation one suggestion proposed by the participants is the icarepd finder resource and a shared tools that support care navigation and linkage with community services examples of informational and technological infrastructure and mediators family orientation programs the idea is to create an informational infrastructure based on key tailored programs that can both inform and guide pwp and connect them to their various networks considering the family orientation is critical and has been emphasized in the literature especially in the benefits it may provide for cp advocacy board a continuous monitoring and evaluation of the integrated care network is required to maintain the efficiency of the model of care patient advisors community representatives and other stakeholders will be included as members of the board consultations with people living with pd and community representatives are an opportunity to engage various actors and discuss new challenges faced by pwp and their families ehealth technologies teleconsultation telemonitoring or telerehabilitation are helpful tools for creating an integrated care infrastructure and positively increasing patient satisfaction and improving continuity of care and communication with the care team the role of these technologies is also described in the literature as important care delivery models to connect individuals from rural and remote locations 36 and in exceptional circumstances such as the covid19 pandemic 39 examples of tools data and resources shared assessment tools some joint care assessment 40 or shared care planning assessments exist to explore the health and social care needs by involving patients and their cp based on the result of this assessment a draft care plan could be codefined and adjusted based on the pwp personal goals needs and expectations this personalization allows us to identify unique personality traits and coping styles that impact care in pd 41 however the implementation of this tool requires trained and specialized nurses who are able to assess medical and social care needs it is also possible to imagine the development of a digital tool that can be shared between the care team to better coordinate care limitations and future research the roadmap and toolkit proposed in this article is based on the results of a canadian case study as such it represents the views and experiences of pwp cp and hcp living in canada specifically the roadmap could be supplemented by incorporating the results of the multinational codesign approach implemented in germany czech republic ireland and france the roadmap and toolkit created serve as a preliminary guide for planning and implementing an integrated care network for people with pd and outline key design features or components that support tailored and personalized care the social cultural geographical and political context of the implementation of an integrated care network must be considered and the network must adapt to these local realities for this reason the elaboration of a roadmap and toolkit does not allow us to define a static and fixed model but to propose key elements that must compose the network to make it adaptable and flexible in different contexts future research could focus on the validation adaptation implementation and evaluation of the roadmap and toolkits conclusions the analysis of current experiences in the journey with pd and codesigning a vision for the future of care has shed light on key components that should compose an integrated care network opp in the form of boundary spanners such as specialized nurses intermediaries in the form of mediators and the creation of infrastructure such as technological or informational infrastructure and inscriptions in the form of health data resources or tools such as tailored educational resources are critical in canada this means that redefining the role of a specialized pd nurse where clear sets of roles and competencies are highlighted creating more personalized care by using health data from technologies such as wearables and developing educational resources that are interactive and allow searching for community supports represent tangible opportunities to advance work toward an integrated care network for pwp data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to ethical reasons our results also highlight the need to consider the future development of therapeutic education tools and support programs for both patients and their care partners or families thus it is relevant to pursue especially in canada a close collaboration with patient associations to propose tools and support programs that are adapted to the different profiles of patients the current challenge for the integrated care network is to be able to adapt and offer tools and resources that are adapted to the needs of remote communities and people with a lower socioeconomic status another element that our study highlights is the importance that the constitution of technological and informational infrastructure will have in the future to support the development of personalized medicine but also close communication with the care team to make the network less reactive and more proactive supplementary materials the following supporting information can be downloaded at figure s1 funding this research was conducted under the framework of the jpcofund2 project integrated parkinson care networks addressing complex care in parkinson disease in contemporary society this is an eu joint programmeneurodegenerative disease research project the project is supported through the following funding organizations under the aegis of jpnd institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the research ethics boards at the ottawa hospital research institute and the university of ottawa for studies involving humans informed consent statement informed consent was obtained from all subjects involved in the study

as part of the icarepd project a multinational and multidisciplinary research endeavour to address complex care in parkinsons disease a canadian case study focused on gaining a better understanding of people living with parkinsons disease pwp experiences with health and medical services particularly their vision for a sustainable tailored and integrated care delivery network the multifaceted nature of the condition means that pwp must continuously adapt and adjust to every aspect of their lives and progressively rely on support from care partners cp and various health care professionals hcp to envision the integrated care delivery network from the perspective of pwp the study consisted of designing scenarios for an integrated care delivery network with patients their cp and their hcp as well as identifying key requirements for designing an integrated care delivery network the results demonstrate that numerous networks interact representing specific inscriptions actors and mediators who meet at specific crossing points this resulted in the creation of a roadmap and toolkit that takes into consideration the unique challenges faced by pwp and the necessity for an integrated care delivery network that can be personalized and malleable so as to adapt to evolving and changing needs over time

introduction hiv and other sexually transmitted infections have been on the rise in panama for the past several years 1 and groups including young adults 2 and indigenous youth 3 are particularly affected as of 2019 hiv prevalence nationwide was estimated at 06 belying significant concentrated epidemics among men who have sex with men and transwomen populations 1 correspondingly sti prevalence is more concentrated among msm female sex workers and adolescents 4 5 6 7 higher hiv and sti prevalence in panama is associated with engaging in sexual activity with new and casual partners due to increased access to connected sexual networks and condomless sex soon after partnership initiation 1 the covid19 pandemic has brought several important changes relevant to sexual health it also created challenges for inperson data collection many population health surveys and other sexual health research activities were initially paused a small number of published studies from north america and europe have examined the impact of covid19 measures on sexual behaviours 8 9 10 however there is a research gap in latin america especially among more isolated rural and indigenous populations there is also little information in the region about how covid19 measures have affected hivsti testing and care services given the relatively high prevalence of hiv and stis in panama and the potential for covid19 measures to affect both behaviours and access to medical care the objective of this study was to examine perceived changes in sexual behaviours and access to key sexual health services during covid19 measures using an online survey based on the association of new and casual partnerships with hiv and stis we focused on identifying factors associated with decreased casual sex during covid19 measures methods this study was an online crosssectional survey conducted as part of the first round of international sexual health and reproductive health a series of surveys conducted in 34 countries to study sexual and reproductive health during covid19 measures 11 ishare panama was conducted from august 8 to september 12 2020 at the end of the strictest covid19 lockdown measures participants reported behaviours from the threemonths period before lockdown measures and during the strictest lockdown measures the survey was advertised on the website and social media of the national public health research institute instituto conmemorativo gorgas de estudios de la salud on social media of nonprofit organisations and individuals and through sms and direct messages sent to individuals and groups who had previously interacted with partner organizations targeted invitation was included in provincial and comarcal social media platforms to increase participation in these regions to better match census population estimates promotion messages asked adults to fill out the survey andor share the survey link no ipaddress restrictions were included as mobile phones are commonly shared within households and among community members study design and populations we used convenience sampling all adults ages aged ≥18 years who saw the social mediawebsitemessages and lived in panama were invited to participate questionnaire creation and study procedures the questionnaire was collaboratively developed with the ishare consortium 11 questions were based on existing survey items and multiitem scales with some new items developed to address the covid19 context 12 the panama instrument was translated from the consortium english into spanish programmed into opendatakit and pilottested with 15 individuals for understanding and acceptability participants completed the online questionnaire in 1030 minutes only items associated with skip patterns were obligatory key variables of interest occurring over the three months before and during covid19 measures included sexual intercourse with a casual partner sexual intercourse with a longterm partner virtual sex use of sexual health services such as hivsti testing and hiv care other influencing variables included age sex gender number of children ethnic group urbanrural residence household and personal income sexual orientation general sexual satisfaction practice of masturbation longterm partner variables and condom use with casual andor longterm partners during the specified time statistical analyses we conducted univariable analyses to describe demographic characteristics we used χ 2 tests to evaluate differences by participants sex and other influencing variables and the differences between urbanrural residence casual sex and sexual activity with their longterm partner three months before and during covid19 measures all participants with valid data were included due to nonresponse on some questions sample sizes varied in addition we examined factors related to perceived decreased casual sex during covid19 measures we undertook a series of three multivariable analyses comparing participants who reported the frequency of casual sex to have stayed the same over the two periods versus those who reported a decrease during covid19 measures having excluded from analysis individuals who reported an increase in casual sex the three models focused on different sets of variables a participant sociodemographic variables b individual casual partner variables c longterm partners behaviours we first used logistic regression to calculate unadjusted bivariable odds ratios and 95 confidence intervals variables associated with the decreased casual sex outcome at p 02 level in bivariable analyses were included in multivariable models as the duration of covid19 measures differed between urban and rural regions we adjusted for residence in the multivariable analyses variables independently associated with decreased casual sex at p 01 were included in the final model to provide adjusted odds ratios and 95 cis controlling for participant gender and urbanrural residence associations with p 005 were considered statistically significant ethical considerations we obtained ethical approval from the comité nacional de bioética de panama ghent university and the university of north carolina at chapel hill for secondary data analysis only participants who gave online informed consent by ticking a box could participate no monetary incentive was provided to participants the survey did not collect whatsapp phone numbers telephone numbers ip addresses or any other identifying information results in total participants from 11 out of 12 panamanian provinces responded to the survey provincial distribution was similar to the 2020 census projection 13 of 960 participants who completed the online questionnaire 526 identified as ciswomen 366 cismen and 68 nonbinary or of another gender the median age was 28 years mixed ethnicity was reported by 555 afrodescendent 106 white 222 asian 17 and indigenous 101 overall 724 identified as heterosexual 78 as bisexual 96 as gay or lesbian and 102 as asexual pansexual queer questioning or another orientation sexual behaviours previous sexual experience was reported by 888 of participants before covid19 measures casual sex among sexually experienced participants was reported by 182 of ciswomen 3245 of cismen and 237 of nonbinary participants of those who reported casual sex always using a condom in such encounters was reported by 506 of ciswomen 612 cismen and 539 nonbinary participants of all participants compared to before covid19 measures during covid19 measures 686 of respondents reported no change 288 reported a decrease and 26 reported an increase in casual sex of participants with a longterm partner sex with the longterm partner and casual sex encounter at least monthly before covid19 measures was reported by 182 of ciswomen 335 cismen and 255 nonbinary participants overall before covid19 measures 471 of participants reported being sexually satisfied supplementary longterm partner relationship and sexual behaviours overall 664 participants reported having a longterm relationship before covid19 measures 504 of whom reported to still be in their longterm relationship during covid19 measures sexual intercourse at least monthly with their longterm partner was reported by 927 ciswomen 825 cismen and 909 nonbinary participants decreases in sex with their longterm partner during covid19 measures was reported by 502 ciswomen 522 cismen and 483 nonbinary participants access to hivsti testing and hiv care services overall 456 participants reported that condoms were more difficult to find during covid19 measures this percentage did not differ between urban and rural areas who reported they needed an sti or hiv test 580 reported they could not receive it due to the covid19 measures this percentage was higher among urban areas however the difference was not significant few participants reported to be living with hiv 8 of whom reported to have had an hiv care appointment cancelled or postponed due to covid19 measures thirteen of the 15 respondents living with hiv were in urban areas and all participants living with hiv reported worrying about art shortages factors related to decreased casual sex during covid19 participant characteristics after adjusting for urbanrural residence cismen were more likely to report decreases in casual sex during covid19 measures compared to ciswomen aor2 16 individual sexual behaviours and virtual sex use after adjusting for participant gender and urbanrural residence an increase in sexual satisfaction was associated with a decrease in casual sex 453 of those reporting an increase in sexual satisfaction also reported decreased casual sex compared to 19 discussion this study examined perceived changes in sexual behaviours use of virtual sex and access to hivsti testing and hiv care during the implementation of covid19 measures in panama our results among a diverse convenience sample of urban and rural dwellers across 1112 provinces expand the literature about sexual behaviours during covid19 measures in latin america we found that overall sexual activity may have decreased among some individuals casual sex widely practised by 182 of ciswomen 324 of cismen and 237 of nonbinary participants precovid decreased for 229 of ciswomen 391 of cismen and 296 of nonbinary participants on the other hand virtual sex also widely practised by 20 to 40 of respondents precovid19 increased for 20 of respondents finally participants reported covid19 measures interrupted access to condoms hivsti testing and worryingly to hiv care for those who needed the services a large proportion of participants reported decreased sexual activity during covid19 measures findings that differ from the latvian ishare study which found most individuals did not have a change sexual frequency during covid19 measures 14 half of panama participants reported decreased sex with a longterm partner this may have been due to extended periods together and increased time with children or other housemates 815 sex with a casual partner decreased among more than onequarter of individuals sex with casual partners has also shown to have decreased in the united states and australia early in the pandemic 81016 a decrease in casual sex partners may provide a unique opportunity for a reduction in behavioural risk but further research is needed nearly half of our participants reported engaging in virtual sex before covid19 measures 20 used cybersex and 40 used sexting at least monthly including in very rural provinces twenty percent of participants reported increased virtual sex during covid19 measures before covid19 measures cybersex use in sweden was found to be slightly higher than what was found in panama 17 some researchers and media outlets had hypothesised that virtual sex might increase during covid19 due to fewer inperson sexual encounters however the first analyses from north america did not demonstrate this 910 interestingly we found that participants who reported to have either increased or decreased virtual sex use were more likely to report a decrease in casual sex compared to those who did not change their virtual sex use our findings indicate that virtual sex use in panama may serve both as a substitute and a preamble to inperson sex a precovid19 metaanalysis found positive correlations between sexting number of sex partners and condomless sex 18 as virtual sex practices emerge as normalized sexpositive tools of sexual behaviour in panama privacy and potential extorsion warnings should be addressed within the applications themselves additionally communitywide campaigns could educate on privacy laws and recommend use of encrypted applications 19 the hiv epidemic is concentrated among specific populations particularly msm and transwomen sti prevalence is high among adolescents and unregistered female sex workers 4 5 6 7 regular testing of hivsti in these populations is considered to aid in controlling transmission interruption of hivsti services may lead to decreased diagnoses and treatment thereby increasing continued transmission and increase in sequelae during covid19 measures in panama access to key services was interrupted with over 50 of those needing hivsti testing not getting it this is supported by an overall decrease of 71 of new hiv diagnoses reported by the panama government during that period 20 a study in australia also found a substantial decrease in hiv tests during 2020 21 hiv testing services elsewhere including latin america have been significantly interrupted during the global pandemic 22 23 24 25 26 respondents also reported disrupted access to sti and hiv prevention and hiv care commodities such difficulties in accessing hivsti testing and care in panama during the covid19 measures may have been related to limited transportation testing facility closures or the covidization of health services panama does not have policies supporting hiv selftesting and sti sample selfcollection as can be found elsewhere globally therefore our findings suggest the need for patient selftesting approaches 2728 that would help maintain continuity of services during national medical crises our study has several limitations first online questionnaires are likely to suffer selection bias as they are only able to include participants who have seen the announcement and are both motivated and able to use online tools however our study used best practices for the conduct of online research during covid19 29 these recommendations include using an online panel for the study design implementing the survey with partner organizations designing the survey for the enduser experience and having a prespecified analysis plan 29 we found that our sample had a similar structure to the 2020 census data in terms of ethnicity urbanrural residence and province of residence except that our sample had more female participants compared to census data this finding is common in health surveys that examine sexual and reproductive health topics 30 thirdly casual sexual encounters may be underreported as over half of our participants were in longterm partnerships additionally memory bias may have enhanced or impaired recall of behaviours from before and during covid19 measures fourthly comparisons between sexual orientation and gender groups should be interpreted with caution given the relatively smaller sample of noncisgender respondents fifthly this paper focused on casual sexual encounters and sexual behaviours in general other related sexual health topics including intimate partner violence access to reproductive health services and mental health will be reported elsewhere sixthly as this is a single behavioural crosssectional study and the capacity for collecting biological samples was limited during this time therefore there should be caution when making any casual inferences from the data lastly this analysis is unable to correlate behaviour with biological outcomes therefore we do not know the impact of behaviour changes on hiv or sti rates our study has implications for sti and hiv research and policy our data suggest the need and usefulness of more rigorous behavioural research during national medical crises and pandemics that have the capacity to disturb normal services while we were able to recruit a convenience sample during the pandemic national panels or other methods can be used to obtain less biased observations 29 these data will be important as lockdown conditions are relaxed and reinforced from a policy perspective our data underline the importance of maintaining the continuity of hivsti testing and care services even during emergency responses conclusions our findings add to the sexual behaviour literature in panama during covid19 we found a decrease in sexual activity among some individuals for casual encounters paralleled with a rise in the use of virtual sex sti and hiv prevention and care services were significantly disrupted during covid19 measures suggesting the need for decentralized services panel c longterm partner relationship and sexual behaviours longterm partner cohabitation reports of increased casual sex not included adjusted for sex and area of residence virtualsex is a composite variable of cybersex use andor sexting use independent correlate media jmp is a distinguished member of the national research system that is supported by the national secretariat of science technology and innovation this study was conducted under the umbrella of the ishare study which examines the impact of the covid19 crisis on sexual and reproductive health in diverse lowincome middleincome and highincome countries the full list of consortium members and their roles can be found here funding funding was not obtained for this study key messages • during panamas covid19 social distancing measures we found a decrease in sexual activity among some individuals especially casual sex encounters among cismen and participants of afrodescendent ethnicity

objectives to describe perceived changes in sexual behaviours including virtual sex sexting and cybersex and access to hivsti testing and care during covid19 measures in panamawe conducted an online crosssectional survey from august 8 to september 12 2020 among adults ≥18 years residing in panama participants were recruited through social media questions included demographics access to hivsti testing and hiv care and sexual behaviours three months before covid19 social distancing measures and during social distancing measures covid19 measures logistic regression was used to identify associations between variables and behavioural changeswe recruited 960 participants 526 548 identified as ciswomen 366 381 cismen and 68 71 nonbinary or another gender median age was 28y iqr2337y 531957 555 were of mixedethnicity mixedindigenouseuropeanafrodescendant ancestry before covid19 measures virtual sex was reported by 385 181470 ciswomen 584 184315 cismen and 450 2760 nonbinary participants during covid19 measures virtual sex increased among 172 ciswomen 247 cismen and 89 nonbinary participants during covid19 measures 230800 288 of participants reported decreased casual sex compared to precovid19 measures compared to precovid19 measures decreased casual sex were reported more frequently during covid19 measures by cismen compared to ciswomen 392 versus 229 urbanrural adjusted odds ratio aor 217 95 confidence interval ci 157301 and by afrodescendant compared to mixedethnicity participants 400 versus 298 aor178 95 ci107294 compared to no change in virtual sex 168 increase in virtual sex 385 aor178 95 ci110288 and decreased virtual sex 867 aor1653 95 ci7743527 were associated with decreased casual sex encounters during covid19 measures hivsti testing could not be obtained by 580 58100 participants who needed a test and interrupted hiv care was reported by 533 815 hivpositive participants conclusions covid19 measures in panama were associated with a decrease in casual sex among cismen and afrodescendant peoples whilst access to hivsti testing and care was seriously disrupted

introduction depression has been recognized as the largest mental health problem internationally 1 it is largely and widely reported in individuals in all age categories from children to elderly adults who are living in both developed and developing countries 2 various factors have been determined to influence the development open access international journal of mental health systems correspondence 2 school of health science mae fah luang university chiang rai province thailand full list of author information is available at the end of the article of depression these factors vary in different groups of people 1 the most significant consequence of depression is suicide 3 the world health organization reported that more than 264 million people were suffering from depression globally particularly people aged 40 years and over 1 southeast asia has been ranked the secondhighest in the world for depression since 2015 4 the who reported that depression accounted for 738100000 years lived with disability worldwide 4 and estimated that 788000 people died of suicide related to depression which accounted for 150 of all deaths worldwide 1 in thailand depression has been considered a major mental health problem for the whole population it has also been reported to occur comorbidly with various physical health problems particularly in women and elderly populations 1 in 2016 the ministry of public health in thailand reported that more than 14 million individuals had been screened for depression in clinics throughout the country among them 17 million had received psychosocial interventions and 07 million were diagnosed with and treated for depression 5 depression impacts individuals at different levels 6 individuals who have depression suffer in interactions with family members friends 7 and community members 8 reduced work productivity is another problem for those suffering from depression 7 most of the suffering individuals do not present clinical signs or symptoms 12 only those who are familiar with and have sufficient information about the disease seek medical care 89 given that many individuals suffering from depression are asymptomatic or have mild symptoms they may not need to seek medical care particularly in the early stages of depression however in the later stages these individuals may need to be cared for and treated properly 6 the treatment and care for depression also take time requiring at least one year for complete treatment approximately 3 months for intensive treatment and 69 months for continual care and monitoring before the cessation of drugs 6 in thailand depression is associated with high medical costs and a large number of medical staff specialize in depression care 10 this is particularly the case in rural areas which are limited in both public health financial allocation and public health personnel to address the problem especially in border areas which are the preferred residential areas of minority and stateless populations 1112 in 2019 the ministry of public health in thailand reported only 25 communitybased psychiatric units with 04 beds per 100000 population which is very limited given the overall thai population of 67 million individuals including hill tribe people 13 most of the hill tribes are located in rural areas and are far from the city especially along the borders of myanmar and laos 1014 in 2019 the who estimated 3540 million hill tribe people living in thailand 15 more than 300000 hill tribe people lived in chiang rai province in 2019 10 the hill tribe people in thailand are also defined as vulnerable populations with respect to several health problems including depression due to specific lifestyles culture diet and other health behaviors such as methamphetamine and opium use 1014 most of these individuals live in poor economic conditions and have low levels of education 16 currently a large proportion of hill tribe people are also facing poor access to health care services due to the lack of thai identification cards which are used for free access to all public services including medical care and the educational system 17 regarding the depression screening instrument only the thai version is available through the thai health care system 18 all the materials used in mental health clinics are developed for trained clinicians there is no version of the tool specific for use in the hill tribe people in the peripheral health care unit located in the hill tribe village furthermore there is no scientific information available regarding depression in the hill tribe population then the study aimed to estimate the prevalence of and determine the factors associated with depression among hill tribe people aged 40 years and over by using the high reliability tool for depression detection methods study design a crosssectional study was used to estimate the prevalence of and determine the factors associated with depression among middleaged and elderly hill tribe populations study setting the study setting was 9 hill tribe villages located in the mae chan district of chiang rai province in northernmost thailand four different tribes were living in the study setting and were recruited into the project the inclusion criteria were as follows hill tribe people aged 40 years and over who had lived in the study area for at least 6 months however those who were unable to provide essential information regarding the study protocol particularly when answering questions related to depression detection were excluded from the study study sample the sample size was calculated based on the standard formula of a crosssectional design n z 2 α2 p e 2 where z is the value from the standard normal distribution corresponding to the desired confidence level p is the expected true proportion and e is the desired precision according to the study conducted by chaiut et al 9 the prevalence of depression was reported to be 329 based on z 196 p 033 1p 067 and e 005 at least 339 participants were needed adding 200 to account for error during the study at least 408 participants were required for the analysis research instruments a questionnaire was developed from the literature review and through discussion with experts in the field to obtain all potential variables related to depression in the hill tribe population moreover intensive and purposive interviews were conducted among 7 health workers who were working in the field and setting namely 2 doctors 3 psychiatrist nurses and 2 public health staff who were working in mental health clinics in their institute and one from a provincial hospital all information gathered was used for questionnaire development there were four parts in the final version of the questionnaire in part i 6 questions were used to collect the general information of the participants such as age sex tribe religion marital status and education level in part ii 6 questions were used to collect information on potential determinants of depression such as occupation income family relationships psychoactive substance use medical conditions such as hypertension and diabetes daily drug use and experiencing stress during the six months prior to the interview date stress was defined as having a difficult time coping with a problem in daily life which resulted in trouble sleeping and a decreased appetite in part iii 20 questions were used to detect knowledge of and attitudes regarding depression and care among the participants in part iv a standard form for detecting depression the thai version of the patient health questionnaire9 which has a reliability of 079 19 was used to assess depression among the participants the reliability and validity of the questionnaire were assessed by different methods the itemobjective congruence technique was used for content validity by three external experts who were working in the field psychiatrists phycologists and psychiatric nurses all experts provided comments to improve the quality of the questions afterward a pilot test was conducted among 15 participants who had characteristics that were similar to those of the study population a cronbachs alpha of 074 was obtained for sections of knowledge and attitudes study procedures the 9 hill tribe villages were selected by a random method from among the 31 hill tribe villages located in mae chan district chiang rai province thailand the district government officer granted the villages permission to participate in the study afterward the village headmen were provided with all essential details regarding the study approximately 5 days prior to the researching arriving at the village the village headmen informed the residents about the study and made appointments for interviews for all villagers who met the inclusion criteria on the date of the interview all participants were provided with all essential information including the objectives of the study to ensure that they clearly understood the project the consent form was obtained before the initiation of the interview in a private and confidential room which was prepared by the village headmen for participants who could not speak thai trained public health volunteers were asked to help them complete the questionnaire the interview took approximately 30 min for each participant data analysis data were doubleentered into an excel sheet before being transferred into the spss version 24 program for analysis categorical and continuous data were analyzed properly to present the characteristics of the participants the chisquare test was used to compare characteristics between people with and without depression logistic regression was used to detect the factors associated with depression at a significance level of α 005 results more than half of the participants were females 4676 were akha 6190 were aged 4059 years and 7637 were married half of the participants were christian had no monthly income and had debt most participants were illiterate and had a primary school education lived with family members had no history of substance use did not smoke and did not use alcohol with respect to depression onethird of the participants had a depression 7574 had mild depression 1788 had moderate depression and 638 had severe depression in comparisons between participants who had depression and those who did not 12 variables were found to be statistically significant sex tribe religion family debt history of psychoactive substance use smoking medical condition stress during the past 6 months reduction in ability to complete housework living independently with no need for interaction with people reduced work productivity within the previous 6 months and knowledge in the univariable analysis ten variables were found to be associated with having depression sex tribe religion family debt history of substance use having a medical condition smoking experiencing stress six months prior to the date of interview living independently with no need for interaction with people and reduced work productivity within the previous 6 months in the multivariable analysis three variables remained associated with having depression in the hill tribe population aged 40 years and over female sex having a history of substance use and experiencing stress 6 months prior compared to males females were 209 times more likely to have depression those who had a history of substance use were more likely to have depression than those who did not and those who had experienced stress 6 months prior were more likely to have depression than those who did not discussion the hill tribes in thailand live in poor economic conditions and have low levels of education people aged 40 years and over are facing a high prevalence of depression and a greater proportion of women than men have depression among the hill tribe people those who had a history of substance use and those who experienced stress in the 6 months prior to the interview had a greater chance of having depression than those who did not abuse substances and who had experienced no significant stress in the previous six months in our study it was found that the overall prevalence of depression which was assessed by the phq9 was 3910 females accounted for a greater proportion of those with depression than did males this finding was consistent with the results of a study conducted in india that reported a depression prevalence of 5630 in females and 3370 in males 20 a systematic review conducted in china in 2017 reported that the prevalence of depression was 2700 a study in croatia reported that the prevalence of depression among people attending primary care clinics was 255 21 a metaanalysis conducted in the united arab emirates found a 125286 prevalence of depression 22 a 2018 study in thailand among the hill tribe elderly population reported that the prevalence of depression was 329 9 however the who estimated that the prevalence of depression was 440 in the general population and there were various rates in different age categories 4 depression has been increasingly reported from 2005 to 2019 among individuals in all age categories particularly in developing countries including thailand 4 in our study we also found that women were at a greater risk than men of having depression in the hill tribe population aged 40 years and over several previous studies reported similar results namely that women are at a higher risk than men of having depression 23 24 25 a systematic study 23 clearly demonstrated that depression was more common in women than men in many countries worldwide kendler et al 24 explained the pathway of factors influencing major depression by sex and among twins and found that women had much more complicated pathways and factors related to the development of depression than men moreover the who reported that women were more vulnerable to depression than men for several reasons such as family economic constraints male dominance in social roles in some communities sex inequity and lifestyle 25 substance abuse was found to be associated with depression in the hill tribe population aged 40 years and over in this study this finding coincides with the results of a study in the united states that reported that people who abused substances were at greater risk of developing depression 26 another study in the united states also demonstrated that substance abuse was significantly associated with depression particularly among adolescents 27 studies in ethiopia have shown that alcohol use 28 and smoking 29 are associated with the development of depression in adult populations moreover in our study stress was found to be significantly associated with depression in the hill tribe population this finding coincides with those of a metaanalysis by yang et al 30 which showed that stress was a major factor contributing to depression in multiple countries particularly in the adult female population moreover a fouryear longitudinal study clearly demonstrated that mental problems including stress could significantly affect depression in canada 31 we have also identified some limitations of this study first due to the hill tribe context in thailand they have no previous understanding concepts or messages related to depression in their life and culture therefore assessing depression by a standard tool developed in other populations may not reflect the real situation however with the available tools and existing information regarding depression among hill tribe people reduced work productivity within the 6 months prior to data collection and a reduction in the ability to complete housework were both found to be associated with depression initially these two new variables were obtained from a group discussion among the hill tribe people living in the village prior to data collection on a large scale therefore these variables need to be carefully considered to determine whether they could be factors associated with the onset of depression among hill tribes using a more robust study method in the future during data collection to ensure that we had obtained highly validated information from the participants a psychiatric nurse who was a member of the research team used several techniques to provide information relevant to depression to all participants before coming up with the specific questions on the phq9 to identify depression in this study however the validity of the phq9 was not determined before its use in the field second when asking questions about stress in the previous 6 months it is difficult to obtain a valid answer from hill tribe people although the term stress is much more familiar to the hill tribes than depression we do not have a standard to detect stress in the previous six months thus the association between stress in the previous six months and depression needs to be detected with a better study design in the future third based on four different hill tribe cultures the lahu have greater difficulty obtaining information particularly in the aspect of mental health problems they are not familiar with talking to people outside the village or to people who do not speak their native language fourth some people thought that depression developed from intrafamily member conflicts and as a consequence family members could not speak to people outside the family fortunately all information obtained from the participants was adjusted and improved through data collection by research team members who were psychiatrists and psychologists before the analysis and interpretation last when performing a crosssectional study it is very difficult to interpret the findings in the sense of a causal relationship between the exposures and depression because these variables are measured at the same point in time therefore further investigation to confirm the associations should be considered conclusion hill tribe people aged 40 years and over are encountering a serious problem of depression especially those who are women have stress and have a history of psychoactive substance abuse due to their living conditions including their lack of education and low economic status the hill tribes in thailand are highly vulnerable to depression however to obtain valid information on depression among the hill tribe people a highly specific and sensitive screening tool for depression particularly in the hill tribe context needs to be developed a health care system is also needed to extend the service to provide proper care and monitoring for those who are found to have significance level at α 005 abbreviations 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 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background depression is globally recognized as a major mental health problem in all age categories particularly among those living in poor economic conditions and with low levels of education including the hill tribe people in northern thailandthis crosssectional study aimed to estimate the prevalence of depression and determine the factors associated with depression in the hill tribe population aged 40 and over in northern thailand hill tribe people who lived in the selected villages and met the inclusion criteria were invited to participate in the study a validated questionnaire and the patient health questionnaire9 phq9 were used for data collection an interview was conducted in a private and confidential room in the selected villages between january and april 2019 logistic regression was used to determine the factors associated with depression at a significance level of α 005a total of 601 participants were recruited into the study more than half 6423 were women 4676 were akha 6190 were aged 4059 years and 7637 were married half of the participants were christian 5707 and had no monthly income 5125 and 85 were illiterate the overall prevalence of depression was 3910 7574 had mild depression 1788 had moderate depression and 638 had severe depression in the multivariate model three variables were found to be associated with depression being female having a history of substance abuse and experiencing stress six months prior compared to men women were 209 times 95 ci 130335 more likely to have depression those who had a history of substance abuse were more likely to have depression than those who did not have a history of substance abuse aor 197 95 ci 125310 those who had a history of stress in the prior 6 months were more likely to have depression than those who did not aor 643 95 ci 420985 public health screening programs to identify depression in the hill tribe population are urgently needed particularly for women those who have abused psychoactive substances and those who have experienced stress

introduction strategies are needed to more effectively promote hiv testing as well as linkage to and retention in care and treatment among individuals living with hiv the salience of such strategies has increased as evidence has grown for the preventive benefit of commencing hiv treatment early understanding how to promote these behaviors is particularly important among men as globally men are significantly underrepresented in hiv testing and treatment services in south africa nearly twothirds of hiv infected men are unaware of their status compared with less than half of hiv infected women men in south africa are also less likely to seek use and adhere to antiretroviral therapy than women and have a greater mortality rate while on art furthermore men play an important role in sexual and reproductive health decisionmaking thus greater engagement by men is likely to impact hiv testing uptake more broadly at the community level to increase mens uptake of hiv testing and treatment services we need a clearer understanding of the social dynamics that shape decisionmaking around engaging in these services gender norms that promote men as strong invulnerable to sickness and selfreliant when faced with illness are major barriers to mens utilization of health services these normative influences on mens behaviors are compounded in communities where hiv stigma is still present this stigma works to drive the epidemic underground making people unwilling to learn their status disclose their status and seek services related to hiv men are influenced in their use of health services by what they think their peers are also doing and are particularly influenced by male peers in the effort to shape these important normative influences to promote hiv testing and treatment interventions incorporating popular opinion leaders serve as useful tools for behavior change at the community level pol interventions have been used effectively in hiv prevention programs and community mobilization interventions which include the use of pol have significant potential to improve mens testing uptake and linkage to and retention in care by addressing the social barriers that deter men from accessing hiv testing and treatment services such as hiv stigma lack of social support and masculine gender norms cm has been used to successfully change hiv risk behaviors and to challenge inequitable gender norms in a range of settings grounded in social diffusion theory the pol approach aims to engage opinion leaders who are community members who have the position and influence to affect the attitudes beliefs and behaviors of others this potential to influence their peers attitudes and behaviors is shaped by the opinion leaders values and traits their competence and expertise in affecting the desired behavior or attitude change and their social position within the community practically pol help to build partnerships with intervention communities communicate behavior change messages and serve as models for behavior change despite the importance of engaging pol in community behavior change programs there is little consensus as to the best method to identify these leaders and methods vary from selfselection to peernomination to sociometric identification often intervention agents identify pol with the help of key informants and community member nominations rather than relying on official leadership or selfnomination this approach can help to identify individuals who are perceived as leaders by their peers as this method of pol identification produces comparable results to sociometric identification and is much less costand timeintensive it is a desirable approach when the ultimate goal is to intervene in multiple communities or to ultimately scale up the pol intervention to empower intervention teams to identify effective pol among men living in rural south africa we need a better understanding of the types of individuals who men in this setting perceive as leaders and the qualities that make an effective informal opinion leader to promote hiv treatment and retention in care specifically we need to understand the nature of informal leadership among men living with hiv in this setting this is no easy task as there are many examples of programs that failed to adequately gain the support of leaders and as a result either never got off the ground or were not sustained understanding who men consider as their informal network leaders will be critical to future enhanced leadership activities to better understand the nature of mens social networks and informal leadership within them we sought to describe mens networks and key social relationships in rural mpumalanga province south africa and to describe the qualities of individuals who men identify as leaders with this information we hope to better understand how to effectively engage pol in mens networks to promote testing and linkage to and retention in hiv care methods study background and setting this study took place at the south african medical research council and the university of witwatersrands agincourt health and sociodemographic surveillance site in the rural agincourt subdistrict of mpumalanga province south africa the study site is located approximately 500 km northeast of johannesburg near south africas border with mozambique the hiv prevalence in mpumalanga is estimated to be 22 among adults ages 1549 by the time men reach the age of 3539 years 45 are infected and the prevalence remains above 15 even into the 70 year and older age group the research team has been conducting a number of studies at the site including a community mobilization intervention that took place from 20122014 focused on changing inequitable gender norms and hivrelated behaviors among young men it was during this study that the team recognized a difficulty in identifying community leaders to effectively partner with in community programming as a result prior to initiating a new community mobilization trial focusing on promoting uptake of hiv testing and treatment the formative data presented here were collected to better understand mens networks and informal leadership in the study communities recruitment and data collection a total of 45 men were purposively selected based upon their hiv status from 14 villages in the hdss catchment area 30 hivnegative men were identified by intervention agents from the aforementioned cm trial 15 hivpositive men were identified through two local clinics both hivnegative and hivpositive men were interviewed as we were interested in understanding personal networks and leadership broadly within the study communities nurses precontacted these men to gauge interest in participating and contact information was provided to the study team for consenting clinic patients structured questionnaires were completed with all 45 men and indepth interviews were conducted with all hivpositive participants and 10 hivnegative participants following completion of the structured questionnaire these groups were chosen to understand variation in mens social relationships and views about informal leadership by hiv status in the structured questionnaire men were asked to list personal confidantes defined as individuals they would be willing to discuss personal matters with and informal leaders or role models defined as individuals whom they admire for each person named as a confidante or leader we asked respondents to report the persons kin relationship the persons gender how long they had known the person whether the person lived in their household or village how close they felt to this person and whether they had ever discussed personal matters related to hivaids with the person after completing the structured questionnaire the semistructured indepth interview began interviewers were able to refer to people named by the participant in the questionnaire portion of the interview the aim of the indepth interviews was to understand 1 who men spend time with on a regular basis 2 where they meet with friends and family 3 what they do with friends and family when they socialize and 4 the qualities that men talk about in reference to individuals they perceive as leaders among their friends and family an interview guide based upon these topics was provided to interviewers who were trained on the aims of the research and the use of the interview guide native xitsongaspeaking experienced qualitative interviewers from agincourt conducted the interviews and also transcribed and translated the audiorecorded interviews into english data analysis data resulting from the structured questionnaire were summarized descriptively using frequency and means tables in sas v 94 we described the size and composition of mens personal networks we also described the characteristics of leaders nominated by participants for both personal network members and leaders we looked at differences in each descriptive frequency and proportion by hivstatus due to the sample size we did not aim to test the significance of differences by hivstatus and thus performed no formal hypothesis tests analysis of the indepth qualitative interviews began with reading the transcripts in full and writing a brief summary for each interview these summaries focused on descriptions of mens relationships and ideas about leadership transcripts were then coded in atlasti version 7 using topical codes based on interview guide questions matrices were created to summarize information across interviews and make comparisons between hivpositive and hivnegative men in these matrices for each interview we summarized the activities men engage in with friends and family how often and where they see these friends and family how they had met the friends they mentioned qualities men attributed to people who they stated they thought of as a leader and how their relationships had changed since disclosing their hiv status to friends and family findings related to each topic were summarized and illustrative quotes were chosen for each point ethical review the study was approved by the ethical review committees at the university of north carolina at chapel hill the university of california san francisco and the university of the witwatersrand in johannesburg south africa individual written informed consent was obtained from all study participants results the 45 interview participants were on average 30 years old of these 45 the 25 men who participated in indepth interviews were slightly older than the group as a whole of the 15 hivpositive participants 10 were actively engaged in hiv care while five were not nearly twothirds of participants were married and over threequarters had attended high school size and composition of personal networks in response to the structured questionnaire participants listed many more family members than friends when asked about people with whom they shared personal matters most participants personal networks included about 7 or 8 people participants named between 2 and 9 family members most commonly naming 4 family members in contrast men only nominated between 0 and 5 friends with most naming between 1 and 3 friends in the indepth interviews participants described spending most of their time at home with family and friends who visit them or at others homes in the village men reported seeing family members and friends who lived in the same village on a daily or neardaily basis relationships with network family members the most common types of family members named in the structured questionnaire were siblings followed by aunts or uncles and parents when asked how often they see these family members in the indepth interview this often depended on whether that family member was away from the village much of the time working for family members living in the same village the participant may see them every day or a number of times a week on the other hand family members living far away may only come home every few months or just a few times on major holidays like easter and christmas many men were very close with and often lived with their mothers about 6 or 7 men specifically mentioned that they saw their mother every day and spent a lot of time together hivpositive men also often expressed gratitude to their mothers who had supported them since their diagnosis the person who helped me that i admire the most more than everyone i listed…is my mom… if it was not for her when i started treatment i would have died so she is the one who i admire the most because she made me to be a man today she was pushing me in a wheelbarrow when i was unable to work you see 36yearold hivpositive man engaged in care in the indepth interviews when asked what kinds of things they do when they spend time with family men most commonly responded that they sit and chat with relatives sometimes participants specified what was often talked about such as life challenges bad and good things a few participants differentiated between family members with whom they talk about general things versus certain family members they discuss serious or important matters with for example one man explained that he sits with his father every morning and discusses family issues with him for some men living with hiv more serious matters included talking about their treatment and how to stay healthy aside from just chatting a few participants mentioned watching tv and a few others described working in the yard or garden together relationships with network friends most participants said they had met their friends in a few different places mainly at school around the village or at work a few participants described having known a friend since childhood one participant had met all three of his friends at work in a nearby large town as he was no longer employed in that town it was difficult for him to see these friends often another participant had met most of his friends at church and one mentioned initially meeting a friend at a drinking venue or shebeen when asked how often they see these friends most participants described seeing one or more friends every day all the time or almost every day many participants also had at least one friend who now lived away from home and who they would only see when that friend could come home on leave every few months or so one participant who himself lived far from his home lamented the fact that he now sees his friends infrequently i can say now i am unable to see them even two months can pass without seeing them when asked what kinds of things they do when they spend time with friends a majority said they meet at each others homes in that setting most men described talking about life or advising each other while a few mentioned watching television others talked more broadly about meeting around the village often secondary places to meet included a shebeen or a soccer field some also mentioned meeting at church a few participants also mentioned staying in touch with friends via cell phones and one mentioned using whatsapp this was true for the man who no longer worked with his friends who he had met while working in a nearby town as it was for a young man communicating with his friends in his same village while at their respective homes we call each other or whatsapp asking what are you doing network relationships differences by hiv status in response to the structured questionnaire hivpositive and negative men reported personal networks of about the same size hivpositive men typically named about two friends or family members known to be living with hiv whereas all 30 hivnegative participants named only three known hivpositive friends and family members in total beyond the frequency of known hivpositive network members there were no clear differences in the composition of mens networks by hiv status during the indepth interview hivpositive participants were asked if living with hiv had affected their relationships none of the 15 hivpositive men said that there had been a change a typical response was no our relationships didnt change and i have never seen a sign to show that they dont like me because im hivpositive one man said his relationships had actually improved similarly when asked are your closest friends still the same as they were before you knew you had hiv all said yes however when asked do you have a new group of friends built around being hiv positive three men of the 15 responded that they did one man gave a specific example of the nature of this new friend group we meet at the clinic when we are there to collect treatment and we encourage each other to take treatment because its our life we ended up being friends since we are all positive and we are from different villages we also buy cold drinks and then we drink together 49yearold hivpositive man engaged in care characteristics of perceived leaders in the structured questionnaire men were asked to name people in their lives who they considered to be leaders over all participants about twothirds of the leaders they named were family members and about one quarter were friends one third of people nominated as leaders were women nearly all of the women nominated as leaders were a family member of the participant in contrast to only about half of male nominated leaders the age of people nominated as leaders ranged from 18 to 85 and on the whole were relatively young nearly twothirds of people nominated were under the age of 40 furthermore there were very few older adults named as leaders only 11 of the 149 nominated leaders were over the age of 60 during the indepth interview men were asked to explain why they had nominated the individuals they named as leaders every single participant was able to speak extensively without prompting about why exactly he chose particular individuals as leaders further participants spoke on this topic with a great level of certainty and little ambivalence about the individuals they had chosen as leaders while the kinds of leadership characteristics each participant identified differed by the individual they were talking about the overarching theme for nearly all revolved around good character primarily demonstrated by showing care towards others in the community often towards the participant himself this often included advising the participant well and providing acts of service his behavior is an example to other people he will encourage you to do good things and protect you from doing stupid things he has his own family but he doesnt forget that he has his mom at home buys groceries for his aunts everyone respects him… 38yearold hivpositive man engaged in care for all participants leadership characteristics rarely included positions in the family or society or having financial means even when such characteristics were mentioned proactively by the interviewer participants perceived this designation of status as only reflection of the good quality of the persons character one participant did nominate a policeman as a leader but added he is always straight and to the point and he is a humble person and is a good example in our family and is very good at making decisions in fact often when the interviewer followed up on a participants proactive description of leadership qualities with a series of probes that included position in the family or being employed the participant would specifically say he did not choose the person for those reasons rather men accepted other proposed characteristics such as exemplary behavior and someone people can confide in as something that made the individual a leader though financial standing did not factor into participants definitions of leadership the ability and willingness to support others financially did for example one man nominated as a leader an individual who had succeeded in life and helped assist others financially to further their studies a sign of his ability to inspire others other participants further focused on being a provider in the family as qualities of the leaders they nominated for hivpositive men specifically over onethird focused on the care and assistance a person had provided them personally when they found out they were hivpositive often including financial support one hivpositive man identified his mother as a leader because …now im ill and not working but shes able to provide me with food and is taking care of me he also identified his uncle who had also provided me with everything since i have been unwell another participant living with hiv described how someone who he thought of as a leader had helped his brother who was also hivpositive i remember my brother was ill and he was the only person who supported me and also provided his car to take him my brother to the hospital or for checkups as seen in these examples financial support as a leadership characteristic was rarely cited in isolation of other types of social support and may have been seen by participants as a further expression of caring on the part of the nominated leader we further asked men to discuss leaders in the community in the fight against hivaids with regard to hiv prevention and support of people living with hiv in the community notably no participant mentioned a formally elected or traditional leader in response to this question though a few men mentioned clinic nurses men again most commonly mentioned people who had demonstrated particular care and concern either for the participant personally or for others in the community in relation to hiv prevention and treatment among hivpositive participants about half did not think there was currently anyone who was a leader in the fight against hiv in their community and most of these individuals couldnt identify anyone who could potentially fill this role in the future discussion our results show that family plays a significant role in mens personal networks in this setting and that confidence and caring are important to trust in extrafamilial relationships and mens ideas of leadership moreover men rarely discussed official community leadership and socioeconomic standing as important characteristic of leaders they mentioned indicating the appropriateness of pol interventions in this setting this points to the importance of identifying pol among hivpositive mens networks to encourage treatment uptake and retention we discuss each of these key findings in further detail below the relatively small size of personal networks and familycentered nature of mens descriptions of their personal networks may be better understood in the context of family life and relationships in the study area which is characterized by high levels of permanent and temporary outmigration apartheid policies disrupted livelihoods and led to the still prevalent labor migration system in south africa today unemployment in the study area is high with an estimated unemployment rate of 29 for men and 46 for women contributing to frequent temporary labor migration approximately 62 of households in the study area had at least one household member absent in 2007 because of temporary migration as many men and women of working age do not permanently live in their home villages it may be difficult for men of working age who are permanent residents to maintain contact with their peers despite the high levels of migration in the study area family relationships are still strong and multigenerational cohabitation may be increasing extended family members also tend to live close to one another and share food and childcare responsibilities taken together the mobility of the workingage population and the continued importance of family in living arrangements may help to explain the small and familycentered networks described by men in this study because of the importance of family it follows that understanding family connections and harnessing informal leadership within family networks will be important to the success of pol interventions in this setting our findings further indicate that the people who men perceive as leaders are friends and family who have been supportive toward them though more family members than friends were nominated as leaders further about a third of the people men nominated as leaders were women though almost exclusively female family members rather than friends together these findings indicate that kinship is important in thinking about informal leadership in this setting and that women should not be discounted as leaders in promoting hiv testing and treatment among men especially when these women are family members of men at risk for or living with hiv it is also important to note that these men made little mention of official leaders notably unlike findings from other african contexts which indicate that mens networks are organized hierarchically by economic status such that perceived leaders tend to be those with the most income or resources participants in this study named people who they believed had good character and behavior and showed caring for others understanding that expressions of caring and social support are high among the characteristics of individuals that men look to as leaders in this context future pol interventions could try to identify individuals who exhibit these characteristics or train peer leaders to build this type of supportive relationship with community members or both understanding and utilizing definitions of leadership from the personal perspective of community members rather than engaging formal community leaders will allow us to adopt a more nuanced approach which is more compatible with the pol model of intervention and may contribute to the success of programs to engage men in hiv testing and care finally we found that hivpositive men were much more likely to have family and friends known to be living with hiv in their network than hivnegative men men living with hiv did not find that their relationships and networks had changed as a result of their hiv status rather many of them found that disclosing their status to family and close friends had strengthened existing supportive relationships this said people may be more inclined to disclose to family members and partners with whom they already have supportive relationships and from whom they would anticipate positive reactions and support upon disclosure of their hiv status hivpositive participants described forming friendships based upon clinic visits and mutual support with other people living with hiv in the effort to understand influential relationships among men living with hiv and leadership within these networks it will be important to consider that shared hivstatus may be an important factor in relationship building rather than assuming that men living with hiv have weakened relationships after disclosing their status interventionists should consider the possibility that positive men may not only have strong relationships with close family and friends but that they may also have new important relationships with other men and women living with hiv pol interventions should consider the behavioral salience of each of the multiplex networks that men belong to for treatment adherence and engagement in care relationship networks among people living with hiv may be just as important as mens personal networks of close family and friends the effectiveness of partnering with hivpositive pol to promote access to and retention in treatment should be explored limitations this study is not without limitations data presented from the structured questionnaire cannot be taken as being representative of the study population as the sample size is small and probabilistic sampling was not undertaken the results of this study do not represent the experiences of all men in this setting or indeed all men living in high hiv prevalence settings in south africa specifically mens networks and relationships may look very different in urban contexts or among men who have migrated from their home communities it is important to note the men in the present study have not themselves migrated but live in a context of high levels of outmigration conclusions the results of this study provide understanding of mens networks and ideas of informal leadership in this high hivprevalence setting which will help to inform future pol interventions such interventions should seek to understand perceptions of leadership in the target population keeping in consideration that elected or formal leadership prestige and social standing might carry less weight in informal opinion leadership potential than capacity for interpersonal support and caring

understanding informal leadership in high hiv prevalence settings is important for the success of popular opinion leader pol and other testing and treatment promotion strategies which aim to leverage the influence of these leaders we conducted a study in mpumalanga province south africa in which we aimed to 1 describe mens personal networks and key social relationships and 2 describe the types of individuals men identify as leaders we administered a structured questionnaire with 45 men 15 hivpositive and 30 hivnegative in which men enumerated and described characteristics of individuals they share personal matters with and people they considered as leaders we further conducted indepth interviews with 25 of these men to better understand mens conceptualization of leadership in their community family members were prominent in mens personal networks and among the leaders they nominated men living with hiv were much more likely to know others living with hiv and described friendships on the basis of the shared experience of hiv treatment future pol interventions aiming to promote hiv testing and care among men in rural south africa should consider the importance of family in community leadership and seek to leverage the influence of connections between men living with hiv

introduction there are two camps of epistemologists those who think that nothing short of subjective probability 1 can warrant assertion and those who think this is untrue and that a person can be warranted in asserting a proposition even if her subjective probability in that proposition is less than 1 in the first camp we typically find those who subscribe to the knowledge rule of assertion a number of distinguished epistemologists have evaluated that rule favorably including keith derose john hawthorne jason stanley and timothy williamson as williamson puts it o nly knowledge warrants assertion to the extent that an advocate of the knowledge rule also takes the standard position that knowledge requires belief he or she will be committed to the view that nothing short of probability 1 can warrant assertion 1 those advocating a truth or belief rule of assertion also belong to this group members of the second camp typically promote a rational credibility or reasonable belief rule of assertion proponents include igor douven frank jackson jennifer lackey and david lewis according to david lewis for example t he truthful speaker is willing to assert only what he takes to be very probably true in a similar vein jackson says that a proposition is assertable to the extent that it has high subjective probability for its assertor douven argues that the debate has led to a standoff between these two camps in terms of the number of prominent researchers belonging to each camp and in terms of how well the two camps deal with objections and problems this may lead one to conclude that there is no fact of the matter ie no objectively valid norm of assertion this would be similar to how people have argued from there being longstanding and widespread disagreement in moral affairs to their being no objectively valid ethical standard alternatively one might infer that the traditional philosophical resources of reflection and intuitionreliance may have been exhausted and that it is time to look for new approaches and new sources of evidence the project to be carried out in this paper is more in line with the second option first rather than viewing the problem of setting the threshold of assertion as basically a problem of individualistic epistemology we will conceive it as a problem in social epistemology our fundamental assumption is captured by the following epistemic principle of assertion rule validity an assertion rule r is valid for a given community c to the extent that r if universally followed by members of c maximizes social epistemic good thus we will ask the somewhat kantian sounding question what choice of a threshold of assertion would if implemented by everyone lead to the best epistemic result for society at large second rather than discussing assertion rules in the abstract as philosophers usually do we will focus on a concrete test case setting the threshold for assertion for a community of inquirers in a social network engaged in group communication concerning the question whether a particular proposition p is the true we will accordingly ask whether the best option is to set the threshold to 1 or whether a lower value should rather be chosen this way of posing the problem corresponds to the philosophical dispute we have just surveyed and any results we obtain will bear on that debate we will depart from tradition finally in asking a question that is slightly more general than the usual one what our investigations will focus on is identifying the optimal threshold in any given case hence if we find that a threshold below 1 is sometimes to be preferred we will not settle for this answer but we will continue asking what the optimal threshold value is 2 a rigorous treatment of these matters requires that we model group communication in social networks in formal terms thus we need to specify for instance what we mean by saying that one assertion rule is socially optimal from an epistemic standpoint and we need some way of determining the goodness of an assertion rule under certain specified assumptions such as the rule assert something only if you confidence is above 09 given the model we are about to present this could in principle be done mathematically in practice however this is far too tedious in section 2 we introduce the concept of veritistic value as a plausible more specific way of understanding the social epistemic goodness of a practice in section 3 we present our bayesian social network model in section 4 we investigate the problem of finding the optimal threshold of assertion using a simulation program that has been devised for the purpose of making mathematical investigations into our favored bayesian model tractable we also test the robustness of our results by varying the circumstances under which they were obtained the last section of the paper is devoted to the question of how best to explain the outcome of our simulation experiments veritistic value we will here give the essentials of alvin i goldmans theory of veritistic value which we will rely on as a plausible and independently supported way of measuring the goodness of a social practice such as the practice resulting from the universal implementation of an assertion rule according to goldman states like knowledge error and ignorance have fundamental veritistic value or disvalue whereas practices have instrumental veritistic value insofar as they promote or impede the acquisition of fundamental veritistic value another key ingredient in goldmans theory is the question and interest relativity of veritistic value an agent ss belief states are said to have value or disvalue when they are responses to a question that interests s for the sake of simplicity goldman chooses to focus much of his discussion on yesnoquestions ie questions of the kind is it the case that p 3 goldmans basic concept is that of a persons degree of belief having veritistic value relative to a question q the idea is simply that the vvalue of persons db in the true answer to a question q equals the strength of the db in goldmans terminology vvalue of db x x suppose for example that mary is interested in the question whether it will rain tomorrow if the strength of marys belief that it will rain tomorrow is 8 and it will in fact rain tomorrow then the vvalue of marys state of belief visàvis the rain issue is 8 4 this takes care of the vvalue of a persons degree of belief our primary concern however is of course to define the vvalue of a social practice so how do we get from individual vvalues to the vvalues of practices as we saw practices have instrumental veritistic value to the extent that they promote or impede the acquisition of states that have fundamental veritistic value suppose for instance that a question begins to interest agent s at time t 1 and s applies a certain practice  in order to answer the question the practice might consist for instance in a certain perceptual investigation or in asking a friend if the result of applying  is to increase the vvalue of the belief states from t 1 to t 2 then  deserves positive credit if it lowers the vvalue it deserves negative credit if it does neither it is neutral with respect to instrumental vvalue the matter does not end here however in evaluating the vvalue of a practice we usually cannot focus merely on the one agent scenario as goldman notes m any social practices aim to disseminate information to multiple agents and their success should be judged by their propensity to increase the vvalue of many agents belief states not just the belief states of a single agent this is why we should be interested in the aggregate level of knowledge or true belief of an entire community to fix ideas consider a small community of four agents s 1 s 4 suppose that the question of interest is whether p or notp is true and that p is in fact true at time t 1 the several agents have dbs visàvis p as shown in the corresponding column practice  is then applied with the result that the agents acquire new dbs visàvis p at t 2 as shown in the column under t 2 table 1 at t 1 the groups mean db in p is 55 so that 55 is their aggregate vvalue at t 1 at t 2 the groups mean db in p is 75 so that this is their new aggregate vvalue thus the group displays an increase of 20 in its aggregate vvalue hence the practice  displays positive vvalue in this application a further complication is that there is a need to consider not just one application of a practice but many such applications in evaluating a practice we are interested in its performance across a wide range of applications in order to determine the vvalue of the practice  in our example we would have to study how well it fares in other applications as well this would presumably mean among other things varying the size of the population of inquirers as well as allowing it to operate on other initial degrees of belief once we have isolated the relevant set of applications against which the practice is to be measured we can take its average performance as a measure of its vvalue it follows from these considerations that when assessing the vvalue of a practice we need to average twice for each application a i of the practice we need to assess the average effect e i it had on the degrees of belief of the members of the society the vvalue of the practice is then computed as the average over all the e i s in that sense the vvalue of a practice is its expected vvalue but for simplicity we will often simply called it vvalue we have now reached the point at which we can state what we will refer to as goldmans fundamental principle of veritistic value the social epistemic goodness of a practice is determined by the degree to which the practice maximizes veritistic value from eparv and pvv we may infer a veritistic principle of assertion rule validity an assertion rule r is valid for a given community c to the extent that r if universally followed by members of c maximizes veritistic value in other words the rule of asserting something only if ones degree of belief has reached a certain threshold if implemented is a social practice this being the case we may ask what veritistic value it has to what degree can a particular threshold of assertion if generally implemented be expected to steer the average member in direction of adopting a higher credence in the true answer to the underlying question the answer to this question will in accordance with vparv be informative concerning the validity of that particular way of setting the threshold a bayesian social network model as we stated in the introduction we wish to evaluate the epistemic or veritistic value of various implemented rules of assertion in a concrete test case for that purpose we envisage a social network of inquirers engaged in joint inquiry into the question whether a given proposition p is the case the inquirer can at any point in time engage in their own inquiries andor assert their current view to their peers in the network formally we can take a social network s to be a set  which we for reasons that will be made obvious shortly will call the set of inquirers together with a binary relation r on  which we call the network structure this means that a social network is a directed graph5 following bayesian tradition the epistemic state of a person α at time t is assumed to be given by a credence function instead of just a set of sentences l can be taken to be a classical propositional language and is assumed to fulfill the standard axioms of a probability measure due to its close connection to probability theory bayesianism is well suited for statistical models and as the models that we will investigate in this paper are of this kind we will adopt the bayesian approach for the purposes of this paper let us confine ourselves to the case where inquiry is aimed at discovering whether a single proposition p is true or false we assume conventionally that p happens to be true since this will simplify calculations further on every inquirer will then have a credence in p which is a real number between 0 and 1 for every moment t in our model there are two fundamentally different ways for the inquirers to receive new information inquiry and communication inquiry can here be taken to include any kind of method of altering a credence function which does not base itself on information given by anyone else in the network the paradigmatic cases of inquiry are observation experiment and perhaps taking advice from persons outside the social network s not all participants approaches to inquiry are the same and they tend to vary both in their degree of activity and their effectiveness let be the proposition αs inquiry gives the result that p at time t be the proposition αs inquiry gives the result that notp at t and the proposition that αs inquiry gives some result at t we represent the participants properties qua inquirers by two probabilities the chance that at any moment t α receives a result from her inquiries and the chance that when such a result is obtained it is the right one to simplify matters we assume that the chance that inquiry gives a true result does not depend on whether p is true or false will be referred to as αs activity and as her aptitude an inquirer without interest in p would generally have a low activity value while one very interested in p but engaging in inquiry using faulty methods would have a high activity value but an aptitude close to 05 or even below that in the latter case the results of her inquiry would actually be negatively correlated with the truth as a simplification we will assume αs activity and aptitude to be constant over time so we will generally write them without the time index t just as inquiry represents the flow of information into the network communication deals with how this information is disseminated analogously to the inquiry notation we define df β says that p to α at t df β says that p to α at t df β says that p or that notp to α at t this strength of a link βα is then representable as a probability being the chance that β communicates that p or that notp to α at any given moment t given so far we have described how the inquirers in a social network engage in inquiry and communication but we have said nothing about how they react to the results of these practices this is the purpose of the following considerations we define αs source σs reliability as r σα df this definition presupposes that the probability that any source gives the answer p if p is the case is to be equal to the probability that it gives the answer notp if notp is the case this source symmetry simplifies our calculations although it can be relaxed if we encounter cases where it does not provide a reasonable approximation it follows at once that the reliability of αs reliability is identical to her aptitude for other sources it is an abstraction based on those sources performances as indications of truth in general an inquirer has no direct access to this value but this does not stop her from forming beliefs about it since the number of possible values for the chance r σα is infinite we need to represent αs credence as a density function instead of a regular probability distribution thus for each inquirer α each source σ and each time t we define a function called αs trust function for σ at t such that for a b in 01 then gives the credence density at  and we can obtain the actual credence that α has in propositions about the reliability of her sources by integrating this function we will also have use for the expression and we will refer to this function as now it is obvious that an inquirers credences about chances should influence her credences about the outcomes of these chances the way this should be done is generally known under a name lewis gave to it the principal principle this says that if α knows that the chance that an event e will happen is  then her credence in e should be exactly  applied to our case this means that the following principle must hold for all t ie αs credence in σ giving the report p given that the source gives any report at all that σs reliability is  and that p actually is the case should be  we also have use for an independence postulate while not strictly necessary such a postulate will simplify calculations and modeling considerably the independence assumption we use here will be referred to as communication independence communication independence implies that whether σ says anything is independent of whether or not p actually is true as well as of what reliability σ has given and we can now define the crucial expressions and the credence an agent should place in p at t given that the source σ says that p or notp respectively as follows where is the expected value of the trust function by the bayesian requirement of conditionalization we must have whenever σ is the only source giving information to α at t this means that these formulae completely determines how α should update her credence in such a case the calculations become slightly more complex when we take into account the possibility of receiving several messages at the same time we refer to angere for a detailed description here we will only hint at the mechanisms involved perhaps the most important idealization is that of source independence we take inquirers to treat their sources as independent given the truth or falsity of p this assumption greatly simplifies the updating of the individual credence functions and it is we submit psychologically plausible as a principle of default reasoning6 not only αs credence in p should be updated however equally important is for α to keep track of how much to trust her sources a source that generally gives very unlikely reports is unlikely to be veridical and an inquirer should adjust her trust function in light of this it turns out that our model already determines how to do this but once more we will not go into the details here suffice it to mention the following consequence of our model even if an inquirer happens to be a perfect inquirer insofar as her inquiry always gives the right result a fairly low stability of her faith in inquiry together with her prior judgment that p is unlikely may conspire to make her distrust her own inquiry this in turn may give rise to a vicious circle in which she becomes more and more convinced that p is false and that her inquiry is negatively correlated with the truth it is time to connect this account of our favored bayesian model with the previous discussion of the veritistic value of a social practice what are social practices in this model and how can we measure their veritistic value let us for a start define the veritistic value v of a social network state let an individual state consist of the values of the epistemic variables of a single inquirer α let a network state be defined as an assignment of values to these variables for all inquirers in a network as well as for the links and a network evolution as a sequence e s 0 s 1 s 2 … such that state s t1 is obtainable from the state s t by having the participants in s t conditionalize on new information according to the model laid out a few moments ago now a social practice  can as a first approximation be viewed as a constraint on such evolutions or equivalently as a set of themthose evolutions that are compatible with the practice but every evolution is determined by its initial state s 0 so we may as well say that the practice is a set of network states which are to be taken as allowed initial states in applications of the practice there is reason to distinguish between two sorts of practices the temporary which are implemented so as to have a projected end and the continual which do not have such an end an example of the first is an investigation made by a committee while the second type includes policies such as free speech the practices we focus on in this paper namely practices of the form asserting something only if ones credence in that thing is over a threshold t also belong to the second category for the first there is for any evolution a specific final state s f and the difference between this state and the initial state appears reasonable to use as a measure this agrees with goldmans own suggestion for how to evaluate practices for a continual practice the problem is harder the only reasonable thing to do may be to identify some finite period during which the practice is to be evaluated this is the line we will take below simulation results our problem now is to vary the threshold of assertion and somehow compute the vvalue of various such choices in that way we could in principle find the optimum threshold for any given situation however the problem is how to carry out this proposal in practice given the complexity of the problem not only do we have to consider all the possible evolutions of a social network but for a practice also all the possible initial states it may be applied to how are we to accomplish this fortunately there is a simulation program available that we can rely on laputa written by staffan angere is a simulation environment for experiments in social epistemology it is intended to be useful for investigating several kinds of models of society but currently it implements the above model laputa allows an experimenter to design social networks to simulate their evolution and to collect some useful statistics includingas we shall seeveritistic values figure 1 a sample social network in laputa when the user hits the run button laputa runs through a series of steps each step representing a chance for an inquirer  to conduct an inquiry  to communicate to the other inquirers to which she is hooked up  or to do both after each step laputa will update the whole network according to the information received by the inquirers in accordance with the underlying probabilistic model previously described laputa contains a highly useful facility called the batch window which allows the user to specify constraints on social networks and to instruct laputa to generate and study a number of networks satisfying the constraints since a social practice can be thought of as a constraint on a network or network evolution this facility allows us to study the effect of a given social practice laputa computes the vvalue of imposing the constraints imposed as minus average error delta for instance the user can instruct laputa to generate and study only networks in which the inquirers say trust each other to a certain degree d trusting others to that degree may be understood as a social practice the output vvalue can be interpreted as the veritistic value of that practice in the context of the other constraints imposed if those other constraints can be considered normal a case can be made that the output vvalue measures the vvalue of the target practice itself we will study a case of barely reliable and wellcalibrated inquirers they are barely reliable in the sense that they are generally 60 percent reliable in their own inquiries they are wellcalibrated in the sense that generally they initially believe that they are 60 percent reliable in their own inquiries and that the same holds true for their peers technically these parameters are normally distributed around 06 with a standard deviation of 015 all other parameters are set to reasonable values as shown in figure 2 referring to figure 2 the flat distribution for starting belief indicates that laputa when selecting the initial degrees of belief for the inquirers in a a generated network will treat all possible degrees of belief as being equally likely to be realized the selection of a normal distribution for inquiry accuracy centered around 06 means that laputa when selecting the inquiry accuracy for the inquirers in the generated networks will have a preference for assigning an accuracy of 06 and surrounding values the population feature allows the specification of the lower and upper sizes of the networks to be examined in this case laputa is instructed to generate and study networks having 2 to 20 inquirers link chance specifies the density of the networks to be studied a link chance of 025 indicates a 25 percent chance that two inquirers will be connected by a communication link in figure 3 the number of trials have been set to 1000 meaning that laputa will generate and study 1000 networks in accordance with the statistical criteria specified in the batch window the first simulation consisted in determining how the vvalue as a function of the threshold value for a case of just a fewin this case 10simulation steps while keeping our background assumptions fixed this means that each network that laputa considered was allowed to evolve for 10 steps each step representing as we saw an opportunity for the inquirers in the network to communicate andor conduct their own inquiries the results are shown in figure 3 figure 3 the vvalue as a function of the threshold of assertion for the case of 10 simulation steps as figure 3 shows the vvalue takes on its maximum for a threshold of about 092 lower vvalues are obtained if the threshold is increased beyond that point this result raised the question whether the maximum would be obtained for the same threshold value regardless of the number of steps in the simulation further simulations showed this not to be the case figure 4 plots the voptimal threshold as a function of the number of simulations steps while keeping everything else fixed figure 4 the voptimal threshold as a function of the number of simulation steps as shown in figure 4 the voptimal threshold increases with the number of simulations steps approaching 1 in the limit the simulations suggested that the voptimal threshold will lie roughly in the interval 09 1 and that the exact position of the voptimal threshold depends on the number of steps in the simulation more precisely the more time there is for inquiry and communication the higher the voptimal threshold so that the voptimal threshold approaches 1 in the limit of inquiry and communication to test how robust these results are we varied other parameters in the model observing how these changes affect the voptimal threshold of assertion after the simulation has gone through 100 steps if the results are robust we should based on the results in figure 4 expect the voptimal threshold to lie somewhere around 099 regardless of the values of these other parameters since we are interested in the limit of inquiry and communication we chose to run the simulation for 100 steps so as to give slow network evolutions sufficient time to converge to results close enough to those in the limit more specifically we varied all relevant parameters one at a time while holding the others fixed at the values specified in figure 2 for each such parameter setting we varied the threshold of assertion so as to find the voptimal one with the following important exceptions the voptimal threshold was found to lie around 099  when all agents already have a sufficiently high initial credence in p 07 a lower threshold will actually be veritistically superior this is explained by the fact that under such circumstances agents are much more likely to communicate p than notp anyway therefore raising the threshold will mostly lead to fewer true messages being communicated however for even higher initial credences 09 there were not any statistically significant differences between the tested threshold values in this case because of the high initial credence agents will be almost equally likely to communicate p regardless of threshold value  when inquiry is negatively correlated with truth a lower threshold value is again more beneficial since r iα 05 most inquirers will end up moving closer to notp and a lower threshold value will therefore allow for more pmessages to be communicated however regardless of threshold value r iα 05 yields a negative vvalue  similarly for inquiry trust when the expected value of the inquiry trust function τ iα  is less than 05 a lower value is better again this will lead to most inquirers moving closer to notp so that a lower threshold value will allow for more pmessages to be communicated  when the expected value of the communication trust function τ βα  is lower than 05 the voptimal threshold is 1 whereas for other values of communication trust it lies around 099 in this case since inquirers are actually reliable having a communication trust lower than 05 will on average lead agents to update in the wrong direction which explains why the voptimal threshold is 1 this threshold removes the misleading information for all other parameter settings we tested the voptimal threshold is around 099 thereby indicating that the obtained results are robust to these changes however it is possible that there could be synergies between two or more parameters we plan to address these possible concerns in future work discussion and conclusion why does the vvalue depend on the threshold of assertion in the way displayed in figure 3 in other words why does fixing the number of steps lead to an optimum somewhere between 09 and 1 we confess that we dont have a clear cut explanation of this fact but we do think there is a reasonable hypothesis available a higher threshold means that less communication will take place and that the inquirer will rely more on her own inquiries in general this is a good thing inquiry provides the inquirer with a direct if somewhat unreliable reality check whereas reports from an informer depend not only on reality via the informers inquiries but also on the credence the informer assigns to the communicated proposition if the informers prior credence is assigned randomly according to a flat distribution as in our experiment this should make the word of others less reliable than inquiry however if there are only a few simulation steps as in this case the inquirer may receive little input from inquiry and so she may have little choice but to lend an ear to her peers even if listening to them is not as reliable a method of belief updating as inquiry itself therefore the optimum threshold will be below 1 if the number of simulation steps is not too large at the same time that optimum will be close to 1 a small threshold will make the inquirer too influenced by communication with the increased risk of error which that brings with it moreover the fewer the simulation steps the scarcer the opportunities to inquire and the more attractive the option of listening to others in other words fewer steps will lead to a lower optimum threshold as witnessed by figure 4 there is an alternative and possibly complementary explanation of the observation of there being a positive dependence between the number of simulation steps and the voptimal threshold it is a general fact about laputa that a society converges normally in a matter of 1530 steps towards an opinionated state ie one in which every inquirer either believes fully that p or fully that notp therefore fewer simulation steps means that fewer inquirers will have time to reach the threshold of assertion given that they started out as in our experiments with a prior credence sampled from a flat distribution if the threshold of assertion is held fixed this means that there will be less communication in the network since people are generally reliable in their inquiries and hence in their communications people when they communicate are more likely to say p than notp given that p is assumed true hence communication everything else equal has a positive general influence on the vvalue hence fewer simulation steps will lead to a reduced vvalue now lowering the threshold compensates for this negative effect by allowing for more communication to take place therefore fewer simulation steps will lead to the optimal threshold being lower as displayed in figure 4 while intuitively compelling this second potential explanation rests on an assumption that is strictly speaking not true that communication in general has a positive general influence on the vvalue we tested this claim by varying the link chance as well as the communication chance as for the former parameter we found that for sufficiently high thresholds the maximum vvalue is reached when link chance 1 however for low thresholds a higher link chance leads to a lower vvalue for some values inbetween the optimum vvalue is attained for a link chance strictly between 0 and 1 as for the latter parameter we performed preliminary tests for threshold values of 06 and 099 for the former the highest vvalue was obtained for communication chance 01 for the latter the highest vvalue was obtained for communication change 04 given these findings it is obviously not correct to say that the vvalue always increases when the link chance or communication chance increases more communication is not always a good thing 7 what remains true however is the fact that there is a positive connection between more communication and higher vvalue although this connection is weaker than we would have expected given a reasonable threshold there is always some positive level of communication that is better than no communication at all 7 see also zollman for a defense of the lessismore thesis regarding communcation zollman also works in a bayesian setting although at the level of details his model is quite different from ours the second explanation relies on a second claim that was also found to be easily testable in our framework the claim that fewer simulation steps will lead to a reduced vvalue this hypothesis was corroborated in our experiments we run simulations with 5 to 50 simulation steps for three different thresholds in all three cases the vvalue increased with the number of simulation steps in summary we suggested that norms of assertion should be evaluated based on their epistemic results for society at large which we identified with goldmans notion of veritistic value the simulation study indicates that the certainty rule is veritistically optimal in the limit of inquiry and communication in finite cases a threshold less than one will be optimal depending on the time available for inquiry and communication and the more time is available the higher is the optimal threshold our robustness test indicated that these results hold so long as the initial credence is not too high and so long as inquiry reliability as well as the expected value of inquiry trust and of communication trust are all greater than 05 future work could investigate whether this also holds when we covary other parameters we started out by noting that there are two groups of epistemologists those insisting that nothing short of certainty can warrant assertion and those insisting that this is not so which group is right our answer is both those who favor the certainty rule are right if their claim is that the certainty rule is optimal in the limit those who reject the certainty rule are also right if their claim is taken to be one about an investigative and communicative process extending over a finite period of time 8

epistemologists can be divided into two camps those who think that nothing short of certainty or subjective probability 1 can warrant assertion and those who disagree with this claim this paper addressed this issue by inquiring into the problem of setting the probability threshold required for assertion in such a way that that the social epistemic good is maximized where the latter is taken to be the veritistic value in the sense of goldman 1999 we provide a bayesian model of a test case involving a community of inquirers in a social network engaged in group deliberation regarding the truth or falsity of a proposition p results obtained by means of computer simulation indicate that the certainty rule is optimal in the limit of inquiry and communication but that a lower threshold is preferable in less idealized cases

introduction the covid19 pandemic has plunged the global economy into panic and trouble 12 it has caused a largescale shutdown of work and production in the whole society which has impacted social and economic development and the overall employment environment and has seriously affected the employment of college graduates as employment is the foundation of peoples livelihood steadying employment stabilizes the economy and peoples expectations livelihood and confidence college graduates are the main force in the job market so promoting their stable and smooth employment is an important part of the harmonious development of the current society and the stable operation of the economy in response to the impact of covid19 on the employment of college graduates the chinese government has launched a series of employment stabilization measures the ministry of education launched a 24365 fullday online campus employment service platform extended the time limit for college graduates to register and settle down expanded the enrollment scale of students in master programs andthe students upgraded from associate degree to baccalaureate etc in addition if the unemployment of college graduates is not properly resolved a waste of talents and social instability will take place social stability is a prerequisite for economic development and social turbulence will inevitably affect the orderly development of the economy for the above reasons scientific evaluation of employment promotion policies for college graduates under the covid19 and corresponding suggestions are of important theoretical and practical significance at present the research on the employment promotion policy of college graduates mostly focuses on the analysis of employment problems and employmentrelated promotion policies from a macro perspective in particular it mainly focuses on theoretical research and the evaluation for the effect of policy implementation for example zhu and chen 3 made comments on the development and reform of the employmentrelated promotion policy for college students after the reform of chinas economic system and put forward suggestions for improving the employment promotion policy ercument and emine 4 conducted the employment evaluation experiment of the students majoring in architecture in hong kong and shanghai and found that improving students ability strengthening specialization and guiding practical ability can effectively promote the comprehensive ability of graduates in group work however there are few literatures from the perspective of policymaking to comprehensively evaluate different policy texts summarize key policy content from them and use relevant comments to analyze the social effects of the policy in view of the inadequacy of existing research this paper uses the policy modeling consistency index model to rate the employment promotion policy for college graduates screens important policy content collects weibo comments on related topics and constructs a support evaluation model for policy measures to respond to college graduates under the covid19 further thepaper analyzes the social implementation effects of the employment promotion policy and finally makes recommendations based on the results of the analysis the structure of the paper is as follows section 2 is a literature review section 3 uses the pmc index model to extract key content in the employment promotion policy for college graduates under the covid19 section 4 uses the policy support degree evaluation model to analyze the impact of policy support degree evaluation model on employment promotion policy section 5 is the conclusions and the future work prospects literature review the current research on employment policy mainly focuses on the following two aspects one is the analysis of the factors affecting employment policy the other is evaluating the effect of employment policy implementation regarding the research on the factors affecting employment policies some scholars have carried out research on individual employability and believed that internal motivation 5 superior expectations 6 and organizational environment 7 are the main factors affecting individual employment innovation ability the typical literature is as follows a study conducted by genco et al 8 at the university of massachusetts showed that freshmen with working experience performed better when given incentives and technical flexibility than general graduates who have obvious differences in incentives and flexibility xu et al 9 proposed that alumni feedback information systems social evaluation systems etc are important resources for improving the quality of talent training in colleges and universities and for guiding and adjusting employment policies zhang et al 10 and yu 11 used questionnaire survey methods to analyze the employment area selection and graduate employment rate of college graduates in different regions yang and yang 12 used regression analysis in mathematical statistics based on a largescale sample survey of employment status of college graduates across the country and studied the factors that affect the employment competitiveness of college graduates including school reputation and status employment service information academic qualifications academic work and work ability employment expectations etc li and lin 13 analyzed the factors that promoted graduates employment and discussed their relations between each other using general system structure theory and they constructed an employment promotion system model and its structure zhang 14 used a bayesian data mining classification algorithm to explore the employment option of college graduates through training the existing data of the employment option of college graduates he analyzed the feedback of graduates that were satisfied with their jobs furthermore he gained the classification feature set rules and established a classification model about the employment option of college graduates it was proved by the experiments that this model was selected user groups with high accuracy based on the survey data of the graduates of jiangsu university for five consecutive years jie 15 adopted the method of gray relational analysis to conduct an empirical study on factors affecting the employment of college students the results showed that there were 15 main factors affecting the employment prospects of college students among them the importance of the ability of active learning was the most important one followed by working ability from the government universities enterprises society graduates and other subjects xi and he 16 analyzed the role of a series of employment promotion and entrepreneurship guidance policies put forward by a provincial government the results showed that the policy had not achieved the expected effect in promoting college students independent entrepreneurship furthermore the propaganda strength of the policy the pertinence of the support object the effectiveness of the policy and the effectiveness of the policy supporting services for entrepreneurship need to be further improved according to the above literature analysis most of the research on employment policies for college graduates uses qualitative methods to explore the influencing factors of employment policies and few policies start from the policy formulation itself to make a scientific evaluation of the social effects after the policy is implemented the research on the evaluation of the implementation effect of employment policies began with edward a suchmans fivecategory evaluation followed by oville f polands three e evaluation classification framework and wollmanns classic policy evaluation 17 yet most of the literature is based on empirical research using case analysis field questionnaire surveys and other methods some examples of typical documents are as follows song 18 takes guangdong province and puts forward suggestions for optimizing policies hu and chen 19 first took 1500 college students in henan province as the survey object and conducted a data survey on all the employment promotion policies of college students in china if the employment policy is very practical and highly recognized by college students it is followed by satisfaction with the employment services provided by the government zhao and yao 20 jointly established the cr2 model and the corresponding projection model and constructed an evaluation index system using the data envelopment analysis method they empirically analyzed the effectiveness of the public employment service policies for college students in china from 1999 to 2006 zhang 21 believes that the historical evolution of the employment policy for college graduates has experienced three stages the planned economic system period the educational system reform and development period and the social entity market economy establishment and development period each stage has its own different characteristics its characteristics are used to solve the employment problem of college graduates the literature shows that most of the research is conducted on specific objects to test the effect of the policy after the release and the research objects of this method are relatively onesided and have certain timeliness in turn such research can neither dynamically grasp the audiences views on the policy in real time nor make optimization suggestions for policy formulation based on the public opinion response of the people to sum up the current academic circles have carried out research on employment policies that rarely combine public opinion with the evaluation and analysis of employment policies therefore this paper starts from the policy text itself ranks policy documents digs out important policy content trawls weibo comments on this basis and uses the comments to construct the employment promotion policy for college graduates under the covid19 to analyze the social effects of policy implementation research framework first this paper collected employment promotion policy documents for college graduates released by the chinese government during the covid19 conducted word frequency analysis and rated the collected policy by pmc index model to select and summarize important policy measures then related topics of 4 kinds of policy measures were searched weibo comments were trawled and an evaluation model of support degree of policy measures was constructed to evaluate and analyze the public support degree of policy measures so as to study the social implementation effect of employment promotion policy for college graduates the framework of the paper is shown in figure 1 namically grasp the audiences views on the policy in real time nor make optimization suggestions for policy formulation based on the public opinion response of the people to sum up the current academic circles have carried out research on employment policies that rarely combine public opinion with the evaluation and analysis of employment policies therefore this paper starts from the policy text itself ranks policy documents digs out important policy content trawls weibo comments on this basis and uses the comments to construct the employment promotion policy for college graduates under the covid19 to analyze the social effects of policy implementation research framework first this paper collected employment promotion policy documents for college graduates released by the chinese government during the covid19 conducted word frequency analysis and rated the collected policy by pmc index model to select and summarize important policy measures then related topics of 4 kinds of policy measures were searched weibo comments were trawled and an evaluation model of support degree of policy measures was constructed to evaluate and analyze the public support degree of policy measures so as to study the social implementation effect of employment promotion policy for college graduates the framework of the paper is shown in figure 1 extracting key contents of employment promotion policy for college graduates selecting and analyzing employment promotion policy in order to extract the key contents of employment promotion policy for college graduates this paper selects the related policy issued by the chinese government from january 2020 to july 2020 during covid19 with reference to the graduation time of undergraduate and graduate students in previous years in the acquisition process fol extracting key contents of employment promotion policy for college graduates selecting and analyzing employment promotion policy in order to extract the key contents of employment promotion policy for college graduates this paper selects the related policy issued by the chinese government from january 2020 to july 2020 during covid19 with reference to the graduation time of undergraduate and graduate students in previous years in the acquisition process following the principles of authority rigor completeness and accuracy the authors collected 16 typical policy documents that have important effects on the employment of college graduates from the websites of the ministry of human resources and social security peoples republic of china the ministry of education the central peoples government and other authority websites as shown in table 1 based on policy text this paper uses rost cm 2223 software to preprocess the policy text such as word segmentation and keyword frequency statistics in order to extract the key content from the policy document the specific process is as follows first the policy text is segmented then the word frequency of the document after word segmentation is ranked and finally the word segmentation results are sorted according to the word frequency from high to low the results are shown in table 2 in addition the ucient software was used to build a cooccurrence network for the documents after word segmentation and the results are shown in figure 2 each node in the network represents a keyword and if there is a line between nodes the keywords have a symbiotic relationship at the same time nodes are displayed according to the keyword centrality if the keyword has higher centrality the keyword frequently appears together with other keywords in the network 24 it can be seen from the keyword frequency distribution and keyword cocitation networks of the aforementioned policy documents that employment service and position rank first among the highfrequency words this is different from the previous situation for college graduates the covid19 has led universities and companies to cancel offline job fairs for the class of 2020 which are the main job opportunities for fresh graduates therefore during covid19 the most important thing for the government is to mobilize all units to implement online employment services expand employment channels and increase employment opportunities from the two highfrequency words entrepreneurship and grassroots level we can see that in order to increase the employment opportunities of college graduates the government has repeatedly mentioned encouraging supporting and guiding graduates to find jobs at the grassroots level stabilizing the environment for innovation and entrepreneurship and giving full play to the important role of mass entrepreneurship and innovation in supporting employment evaluating employment promotion policy documents for college graduates based on pmc model at present the more advanced international policy text evaluation method is the pmc index evaluation model established by estrada 25 this model believes that everything is constantly in motion and interconnected so any relevant variable cannot be ignored its innovation is that it uses binarydigits 0 and 1 to balance all variables and emphasizes that the number and weight of variables should not be limited so that the advantages and disadvantages and internal consistency of a policy can be analyzed from various dimensions 26 most existing policy evaluation methods have problems such as strong subjectivity and low accuracy however the pmc index model method can largely avoid subjectivity and improve accuracy because it obtains raw data through text mining in addition the effectiveness of the pmc model has been verified in the literature 25 in the policy analysis in this paper the pmc index model takes variables into extensive consideration which not only can comprehensively analyze the merits and demerits of a policy but also has the advantages of index traceability and grade identification and scientifically quantifies the consistency level of each policy from different dimensions therefore this paper introduces the pmc index model to quantitatively evaluate the employment promotion policy for college graduates under covid19 and obtains the key points of the policy content from the outstanding policy documents with a pmc index score of 910 generally the establishment of a pmc index model includes the following steps establishing a pmc index evaluation index system establishing a multiinputoutput table and calculating twolevel variable values and pmc index classifying the variables and setting parameters of pmc index model referring to estrada and the existing literatures 27 28 29 and combining with the specific characteristics of college graduates employment promotion policy this paper establishes 10 firstlevel variables and 66 slevel variables the results are shown in table 3 table 3 pmc evaluation variables of employment promotion policy for graduates firstlevel variables secondlevel variables no secondlevel variables name secondlevel variables no secondlevel variables name nature of x 1 policy x x 3 x 4 x 5 x 6 x 7 x 8 x 9 x 10 first determine the value of the secondlevel variable x ij according to formula then calculate the value of each firstlevel variable according to formula and finally bring each firstlevel variable into formula to calculate the pmc index of different policies the pmc index evaluation criteria can be obtained from the literature 21 910 points 7899 points 5699 points 0499 points this method obtains the ranking and rating of the pmc index of the employment promotion policy for college graduates and the results are shown in table 5 from the evaluation results in table 5 it can be seen that among the 16 college graduate employment promotion policies eight of the policy evaluation results are acceptablelevel or above accounting for 50 among which two are perfect and the policy content contained in the perfect policy document is more comprehensive the target audience is wider and the steps involved in the implementation measures are more detailed therefore in order to extract the key points in the policy documents the contents of the p 3 and p 5 perfectlevel policy documents are selected and summarized due to the diversity of the measures proposed in the policy and their different focuses the content of the policy is divided into four areas increase the opportunities for further education and reduce the number of fresh graduates who are in urgent need of employment broaden employment information circulation channels and guide universities and colleges to carry out extensive online employment provide employment subsidies lower employment restrictions alleviate employment anxiety of recent graduates and improve employment benefits of recent graduates increase position and increase labor demand according to the above four aspects the employment promotion policy measures for college graduates can be divided into four categories channel measures transference measures subsidy measures and position measures analyzing social effects on employment promotion policies for college graduates as a reflection of public sentiment and public opinion online public opinion not only manifests its influence on major developments but also penetrates into the political level becoming an important channel for the government to listen to and understand public opinion in order to dig out the publics attitude and response to the official employment promotion policy under the covid19 pandemic the corresponding topic comment information on the weibo is crawled and social implementation effect of employment promotion policy is analyzed based on the comments acquiring and preprocessing data acquiring data this paper searches related topics for 4 kinds of measures on weibo and selects the 15 topics discussedmost frequently as the data crawling objects each topic is shown in table 6 this paper trawls the related weibo comments on 15 topics the trawled content includes the publisher id the content of the comment comment time commenter id the number of followers the number of subscribers and weibo number this paper uses python to obtain a total of 65487 posts including 9596 posts for channel measures topics 17003 posts for transference measures topics 7671 posts for subsidy measures topics and 28849 posts for position measures topics the data format is shown in figure 3 special post teachers plan to increase recruitment by 5000 develop research assistant position to attract college graduates this paper trawls the related weibo comments on 15 topics the trawled content includes the publisher id the content of the comment comment time commenter id the number of followers the number of subscribers and weibo number this paper uses python to obtain a total of 65487 posts including 9596 posts for channel measures topics 17003 posts for transference measures topics 7671 posts for subsidy measures topics and 28849 posts for position measures topics the data format is shown in figure 3 data cleaning because invalid data and incorrect data inevitably appear in the trawling process these data are rarely utilized in the analysis process or cause large errors in the results thusthey need to be deleted data cleaning mainly deletes repeatedly collected data repeated expression words shorter sentences meaningless or unclear sentences after data cleaning a total of 61311 valid posts were obtained word segmentation and word frequency statistics as the content of the comments are all in chinese the jieba chinese word segmentation package 31 is used to perform word segmentation on the weibo comments in the python environment and remove stop words that cannot represent text characteristics because the research object of this paper is the employment policy for college graduates under covid19 pandemic the nouns that appear frequently in the document after word segmentation are student society employment etc such words are more neutral and have less meaning for word frequency analysis therefore this type of word is also added to the stop word dictionary on this basis the top 100 effective highfrequency words are sorted out as follows teacher quota postgraduate epidemic fresh graduate fractional line condition file previous graduate fulltime employment rate labor force talent young people master quality civil servant parttime housing price wuhan workload research assistant proportion normal major doctor guangdong qualification written examination special post teacher chongqing student source mathematics college promotion unit age college threshold preliminary examination junior college student origin sichuan energy household registration reexamination unemployment rate poor student welfare enterprise area level accomplishment bachelor doctoral student shandong henan junior college registered residence treatment beijing elementary school salary subsidy university head teacher interview tripartite agreement vocational school contract rural area preschool education ability anhui township undergraduate shanghai region city second degree whole country government office hospital institution kindergarten domicile chinese art engineering nurse pressure agreement expe data cleaning because invalid data and incorrect data inevitably appear in the trawling process these data are rarely utilized in the analysis process or cause large errors in the results thusthey need to be deleted data cleaning mainly deletes repeatedly collected data repeated expression words shorter sentences meaningless or unclear sentences after data cleaning a total of 61311 valid posts were obtained word segmentation and word frequency statistics as the content of the comments are all in chinese the jieba chinese word segmentation package 31 is used to perform word segmentation on the weibo comments in the python environment and remove stop words that cannot represent text characteristics because the research object of this paper is the employment policy for college graduates under covid19 pandemic the nouns that appear frequently in the document after word segmentation are student society employment etc such words are more neutral and have less meaning for word frequency analysis therefore this type of word is also added to the stop word dictionary on this basis the top 100 effective highfrequency words are sorted out as follows teacher quota postgraduate epidemic fresh graduate fractional line condition file previous graduate fulltime employment rate labor force talent young people master quality civil servant parttime housing price wuhan workload research assistant proportion normal major doctor guangdong qualification written examination special post teacher chongqing student source mathematics college promotion unit age college threshold preliminary examination junior college student origin sichuan energy household registration reexamination unemployment rate poor student welfare enterprise area level accomplishment bachelor doctoral student shandong henan junior college registered residence treatment beijing elementary school salary subsidy university head teacher interview tripartite agreement vocational school contract rural area preschool education ability anhui township undergraduate shanghai region city second degree whole country government office hospital institution kindergarten domicile chinese art engineering nurse pressure agreement experience kindergarten teacher counselor downtown tianjin other province music english news county town construction of evaluation model for supporting policy measures an evaluation model for supporting policy measures is constructed here to evaluate and analyze the public support degree of the four types of measures summarized by the above pmc index model to study the social effects of the implementation of the employment promotion policy for college graduates constructing evaluation dimension the degree of support for policy measures needs to be analyzed from multiple dimensions including the theoretical goals of the policy measures the peoples expectations of the policy measures and the specific implementation methods of the policy measures most of the previous studies analyzed the policy support degree from one dimension the coverage of the policy is relatively narrow and lacks objectivity which affects the scientific statistical results in order to improve the credibility of the research results this paper refers to the various evaluation dimensions adopted by the existing research and redefines the evaluation dimensions starting from multiple dimensions it analyzes the degree of public support for various measures of college graduate employment promotion policies the dimensions are shown in table 7 table 7 evaluation dimension evaluation dimension comments dimension definition theoretical objectives the theoretical effect to be achieved at the government level under the preset expectations of policy measures since the epidemic is so severe this year it is necessary to introduce policies to ensure employment expectations of the masses expected effects of policy measures at the public level with postgraduate enrollment expansions the graduate degree will be worthless in the future implementation means specific implementation methods and processes of policy measures the policy was issued too late the school has already sent the files back target groups the main body of policy measures hope this policy is not just for fresh graduates constructing comment topic identification system as netizens often evaluate policy measures from different positions and perspectives each comment may correspond to different evaluation dimensions this paper uses the framework semantic dictionary matching method takes the policy review subject word dictionary as the label system and completes the identification of the corresponding dimensions by extracting and matching the evaluation words of comments among them the policy review topic identification word dictionary is mainly generated based on the frequency of keyword in the comments combined with manual selection due to the large number of identified words the semantic logic induction method is used to summarize and refine it sixteen themes are generated national condition human resource work treatment work intensity learning form school roll employment agreement employer position examination enrollment region education subject student type and applicable condition combining the evaluation dimension system constructed in table 7 and the corresponding 16 themes with 4 evaluation dimensions a comment topic identification system is obtained as shown in table 8 this can avoid semantic confusion caused by a large number of topic words thereby improving the data structure and clarifying the evaluation dimension to which the text belongs the abovementioned comment topic identification system is used to map comments to different evaluation dimensions by identifying and matching comments a total of 51567 pieces of comments related to 4 evaluation dimensions were extracted the specific results are shown in table 9 determining policy theme weight tfidf weighting method is used to assign weight to each topic here the tfidf method consists of two parts the tf method and the idf method the tf method is to count the keyword frequency the basic idea is the more times a word appears in the document the stronger the word is to summarize documents the idf method counts how many documents a word appears in the basic idea is if a word appears in fewer documents its ability to distinguish between documents is stronger the calculation formula of the tfidf method in this paper is tfidf n i ∑ k n k × log d 1 d i where n i refers to the number of times the topic recognition word n i under the ith topic appears in the review data ∑ k n k is the total number of words in the corpus and the result of dividing the two is the word frequency d refers to the number of comments in the corpus d i is the number of comments containing the topic identification words under the ith topic and the logarithm is the inverse document frequency the product of the word frequency and the inverse document frequency is the tfidf weight of the ith topic from this the weight of each theme can be obtained as shown in table 10 a theme with a weight greater than 01 has a significant impact on policy support degree and is called a key theme as can be seen from the above table there are a total of six key themes in the position measures work treatment employer position enrollment subject and student type this shows that the number of new jobs were created by position measures and that the employment requirements of these new jobs have a greater impact on the public support degree of positional measures there is a total of four key themes in the transference measures examination region education and student type this shows that the specific arrangements for entrance examinations and the objectoriented fairness of the measures have a greater impact on the public support degree of transference measures there are 4 key themes in the channel measures human resource employer position and region this shows that the effectiveness of policy measures in alleviating the employment situation and the fairness of the policy in terms of geographical terms have a greater impact on the degree of support for position measures there are 5 key themes in the subsidy measures enrollment employment agreement employer student type and applicable condition this shows that the implementation has a greater impact on the degree of support for subsidy measures calculating theme emotion score due to the use of sentence structures such as irony in weibo the results obtained by the traditional dictionarybased lexical weight accumulation algorithm are not ideal because internet irony often uses some exaggerated rhetoric to express dissatisfaction and irony such comments often contain strong emotional colors in order to ensure the accuracy of the emotion score it is very important to accurately identify and score this type of comments therefore this paper identifies these sentences and revises the emotion score based on punctuation features to improve the accuracy of the results calculation of initial emotion score the emotion score of a sentence is not only determined by the emotion evaluation word itself but also affected by degree adverbs negative words and punctuation in order to improve the accuracy of the emotion score calculation this paper combined the comment and the chinese grammar dictionary selected 117 degree adverbs and defined their respective emotion strengths the results are shown in table 11 aiming at the negative words appearing in the comments this paper combines the original negative words in hownet dictionary and the common phrases in weibo to sort out a total of 27 negative words after manual screening in addition to degree adverbs users often use continuous punctuation to reflect their own emotions in this regard the punctuation at the end of the comment will be identified and the emotional intensity of various punctuation will be set as shown in table 12 below punctuation emotion strength × n 15 × n × n 12 × × n 08 × n in summary the initial emotional score of the ith comment e i is expressed as follows e i n ∑ j n j w j p m q ∏ j l j where w j is the jth emotion score in comment and l j is the emotion strength of degree adverbs before the jth emotion word n j is the number of negative words before the jth emotion word p m is the emotion strength of punctuation at the end of the comment q is the amount of degree adverbs before the jth emotion word modifying emotion score of irony in the chinese context irony has various manifestations and the most common form is rhetorical question when identifying rhetorical questions the biggest challenge lies in distinguishing interrogative sentences from rhetorical questions the common feature of the two is the ending of the question the difference between the two is that rhetorical questions often contain vocabulary with a certain emotional inclination while interrogative sentences do not contain emotional inclination therefore the rhetorical question processing rules are as follows e i 1 × e i e i ending with the question and e i 0 other emotion score of various themes after the above calculation the emotion scores of various policy themes are obtained and the results are shown in table 13 it can be seen from table 13 that the highest emotional score among position measures is national condition with a score of 09016 indicating that the public believes that position measures can increase the employment rate of college students and reduce the impact of covid19 on the economy among position measures the lowest emotion score is work intensity with a score of 12313 which shows that the public believes thattreatments of new jobs brought about by position measures needs to be improved among the transference measures the highest emotion score is the examination with a score of 12514 indicating that the public believes that the transference measures have a positive impact on the entrance examination among the transference measures the lowest emotion score is the subject with a score of 17181 indicating that the public believes that the subject is not comprehensive enough among the channel measures the highest emotion score is national condition with a score of 05156 indicating that the public believes that channel measures have a positive impact on increasing the employment rate and promoting the rapid employment of college graduates among the channel measures the region with the lowest emotional score is the region with a score of 19725 indicating that the public believes that the geographical area targeted by the transference measures is not comprehensive enough among the subsidy measures the highest emotion score is work treatment with a score of 23995 indicating that the public believes that subsidy measures can effectively improve their own work treatment among the subsidy measures the lowest emotion score is school roll with a score of 36528 indicating that the public believes there are some unreasonable aspects in the means related to school roll in subsidy measures analyzing support degree for various policy measures the public support degree for various employment policies is calculated based on the topic weights and emotion scores obtained above the formula is s ∑ te where s is the public support degree for the policy measures t is the theme weight and e is the theme emotion score according to the abovementioned public support degree for various measures the results are shown in table 14 it can be seen from table 14 that the support for the four types is negative indicating that the public has a negative attitude towards the employment policy for college graduates under covid19 among them the degree of support for position measures is close to 0 indicating that the public holds a neutral attitude towards position measures as the range of support degree for policy measures set in this paper is 55 although the support degree for transference measures is negative its value is approximately 01 which is still in the neutral range the support degree of subsidy measures and channel measures is lower than 1 indicating that the public is not satisfied with these two types of policies and there is room for further improvement combining tables 10 and13 it can be found that the emotion scores of worktreatment employer and position in the key themes of the position measures are positive indicating that the public is satisfied with the treatments of newly added positions however the emotion score of the enrollment is negative and less than 1 indicating that the number of new positions is not satisfactory in addition the emotion scores of subject and student type are less than 0 indicating that the public is dissatisfied with the subject and academic qualifications of graduates for newly added positions this also reduces the support for position measures so support for position measures is relatively neutral for transference measures under the dimension of implementation means examination has the largest proportion and positive emotional score which makes the support of this dimension positive indicating that the public is satisfied with the fairness of the publics specific implementation however note that the weight of target groups is 04743 which is close to 50 and the support for this dimension is 03631 which makes the overall support degree for transference measures not high in addition the support degree for the theoretical objectives and the expectations of the masses is also negative this is because the people believe that the transference measures are a temporary solution but not a root cause and may bring about social problems such as depreciation of academic qualifications after implementation the emotion scores of the four key themes in the channel measures are all negative and all are less than 1 which is the main reason for the low final support degree of the channel measures many people believe that the employment information platform established by channel measures is not well known moreover the policy is mainly for fresh graduates in hubei the coverage of the policy is not wide enough in the evaluation dimension of subsidy measures the emotion score of implementation means is close to 2 and the weight reaches 04586 in addition the emotion score of target groups is also lower than 1 which makes the overall support degree for subsidy measures poor the public believes that the channel measures on student status are not well implemented and the policies are only targeted at individual regions thus many regions cannot feel the employment convenience brought by the policy conclusions this paper introduced the pmc index model to quantitatively evaluate the employment promotion policy documents of college graduates under covid19 pandemic at first then itobtained six acceptablelevel policy documents and two excellentlevel policy documents summarizedfour measures according to the key contents of policy documents as well as constructedsupport evaluation model and analyzed the social effects of the employment promotion policy for college graduates under covid19 pandemicthe results showed that the public was generally not satisfied among them the public had a neutral attitude towards position measures and transference measures but was obviously dissatisfied with subsidy measures and channel measures in this regard the government should improve and optimize the existing employment policies based on the analysis results this paperput forward the following suggestions the public expresses dissatisfaction with the geographical coverage of the four types of measures and the breadth of population coverage in this regard the government should optimize adjust and expand the subjects and student types covered by the employment policy for college graduates at the same time local governments should learn from the advanced experience of other regions to narrow the gap in the implementation of policies among regions so as to ensure that policies can bring equal benefits to graduates from different regions schools and disciplines in response to the shortcomings of existing position measures the government should steadily increase the number of recruits of government agencies and institutions and can appropriately relax restrictions on the recruitment of subjects and academic qualifications according to the work content and needs of different positions the government first needs to pay attention to the problem that transference measures treat the symptoms but not the root cause proposed by the public second the government needs to deal with the problem of difficulties in obtaining employment for college graduates from a more longterm perspective it is necessary to foresee that college graduates transferred by transference measures will face employment pressure again in a few years therefore plans should be improved in addition in response to the depreciation of academic qualifications caused by the implementation of transference measures the government needs to realize industrial upgrading as soon as possible and create more jobs that require highend talents to meet the growing demand for highquality talents in society in response to the shortcomings of channel measures first the government should increase the promotion of employment information platforms for college graduates and cooperate with social platforms and short video platforms commonly used by young people to increase the popularity of the platform second the government should cooperate with leading companies in various industries to introduce large companies to the platform and drive many small medium and microenterprises to settle on the platform in addition the government should also cooperate with various universities to guide college graduates to make better use of the platform and increase the utilization rate of the platform in response to the shortcomings of subsidy measures relevant government departments should strengthen supervision and ensure that relevant units and enterprises in various regions implement policies and measures so that college graduates can truly feel the effect of subsidy measures however this paper still had the following shortcomings which need further study the research object of this paper was the employment promotion policy for college graduates issued by the government from january to july 2020 the impact of the covid19 epidemic is still not finished yet and the government will issue new employment promotion policies therefore further analysis of the effects of the new policy will be carried out in the followup this paper mainly analyzed the social effects of the implementation of the employment promotion policy for college graduates under the covid19 pandemic so the economic effects of the policy implementation should be analyzed in the followup as well based on the data of chinas weibo 36 this paper evaluated the implementation effect of the employment policy for college graduates issued by the chinese government however covid19 has an impact on all countries in the world therefore in the future we will collect data from all countries conduct targeted research and give corresponding suggestions data availability statement the data used to support the findings of this study are available from the corresponding author upon request firstlevel variables secondlevel variables no secondlevel variables name secondlevel variables no secondlevel variables name issuing agency of x 7 policy x the weights of the secondlevel variables in table 3 are set to the same value and all the parameter values of the secondlevel variables are set to binarydigits 0 and 1 if the content of the policy document involves the meaning of the secondlevel variables it is assigned the value 1 otherwise it is 0 constructing inputoutput table the inputoutput table is a data analysis framework that can store a large amount of data and use multidimensional measurement of a single variable it is composed of numerous firstlevel variables and secondlevel variables that are not restricted by variables the firstlevel variables have no fixed order and are independent of each other and the weights of the secondlevel variables are equal 30 as shown in table 4 the secondlevel variables values are assigned according to the keywords obtained in section 41 when the policy text data contains the keywords corresponding to the secondlevel variables the value is assigned to 1 otherwise it is 0 compared with the subjectivity of expert scoring this method is more objective and scientific firstlevel variables secondlevel variables calculating pmc index the pmc index of the policy documents in table 1 is calculated below the calculation method is as follows i is firstlevel variables j is secondlevel variables ij 12345 ∞ n is the amount of secondlevel variables n informed consent statement informed consent was obtained from all subjects involved in the study

as an important part of human resources college graduates are the most vigorous energetic and creative group in society the employment of college graduates is not only related to the vital interests of graduates themselves and the general public but also related to the sustainable and healthy development of higher education and the countrys prosperity through science and education however the outbreak of covid19 at the end of 2019 has left chinas domestic labor and employment market in severe condition which has a significant impact on the employment of college graduates based on the situation the chinese government has formulated a series of employment promotion policies for college graduates in accordance with local conditions to solve the current difficulties in employment of college graduates during the covid19pandemic do these policies meet the expectations of the people is the policy implementation process reasonable all these issues need to be tested and clarified urgently this paper takes the employment promotion policy of college graduates under the covid19 as the research object uses the pmc index model to screen the policy texts obtains two perfect policy texts and uses the weibo comments to construct the evaluation model of policy measures support degree to analyze the social effects of employment promotion policies for college graduates the results show that the publics support degree with the employment promotion policies for college graduates under covid19 needs to be improved among them the public has a neutral attitude towards position measures and transference measures but is obviously dissatisfied with subsidy measures and channel measures finally suggestions for improving policy are given to make the employment policy in line with public opinion and effectively relieve the job hunting pressure of college graduates

introduction for the calm that you most need that you can only find if you dont try to fit everything together at the beginning of our visit with andréia fornato in 2002 1 my daughter emma and i chatted with andréia and her family as her sons set out snacks when it came time to turn to the formal video interview wed arranged for that afternoon on the history of andréias activism in the movement of rural women workers 2 we asked andréia where shed like to conduct the interview she took us out to her yard and stood squarely in the middle of it as we set up our tripod camera and microphone when the interview began she proceeded to show us the trees in her familys small orchard we have some trees that are symbols of rio grande do sul brazil one of them that id like to present is the pine tree or the araucára which is native and is this huge tree here the tallest one also we have fruit trees for this season which for us is winter we have bergamota and orange which are also native then we have a bergamota tree with the fruit still on the branch that small one after describing the trees andréia took us back to the 1980s and 1990s when she worked together with other young women in her town of maronata and the surrounding countryside to form the mmtr in the southern brazilian state of rio grande do sul andréia began her narrative with her parents describing her fathers efforts to create a responsive farmers union along with his insistence that mornings spent at school be followed by farm work at home she also described her mothers activities running the domestic sphere of the household andréia explained that her mother rarely expressed opinions and had no say in the economic affairs of the household or disciplining of the children she told us in her characteristically matteroffact way that didnt sit well in my head and went on to describe years of grassroots organising in the womens movement to change the economic exclusion and social isolation of women in the countryside andréia also told us about her work in the farmers union and the challenges she had faced to become the first woman president of the local union in her town an hour later after the conclusion of the interview andréia took us to a different part of her garden and set about showing us the full contours of a cassava plant which involved pulling the large root vegetable out of the ground declining help from emma andréia tugged and tugged until the cassava emerged smiling broadly as she displayed it to us in framing our interview between the trees in the orchard and the cassava in the vegetable garden i think that andréia meant to evoke her own rootedness and that of her political militancy in the ground on which she herself had grown up and the family of which she constituted an integral and equal part indeed in the course of the interview andréia referenced the floorboards in her house and the way new planks intermingled with wood from the original house which had belonged to her husbands parents the fact that andréias sons served us snacks taking on a role conventionally reserved for women and girls represented a striking result of her efforts to build differently on that intergenerational floor in the course of two decades of activism andréia used her early life experiences and the sensibility that emerged from them to develop a vision of radical politics and activism focused on reforming the economic and social relations around her in her family community and region andréias personal history which included the union and church leaders who had ignited her activism led her to base this vision of economic and social change on notions of subjecthood and dialogue this occurred amid what an early colleague in the mmtr anisia santos the first woman president of the farmers union in another town characterised as the whole process of gender which in anisias view involved interlocking issues of land agricultural work family relations community activity and finance andréia and anisia applied the lessons of their pasts to both their family life and political activism by developing the capacity to recognise and balance multiple experiences and understandings simultaneously isabel toneli another founding member of the mmtr who was raised in maronata but spent much of her adult life in andalinas 3 reached similar conclusions about holding multiplicity for isabel this developed in the course of years of organising work for the mmtr talking to women in their homes at church and at movement meetings in presenting a gendered analysis of womens economic and social subordination in their families and communities isabel gained supporters for the womens movement but she also came up against commitments and refusals that led women to hesitate to join the movement or attend its events as she enumerated these constraints i asked isabel if fighting for new understandings and practices of gender and agriculture became harder as she became aware of the complexity of womens lives and of womens ambivalence towards changing longstanding relationships and practices isabel answered directly and in an uncharacteristically personal fashion she was drawing she said on her reading of the brazilian educator and activist paulo freire each person is different each conversation isabel explained therefore she said in order to transform the world you have to reach inside yourself for the calm that you most need that you can only find if you dont try to fit everything together in acknowledging the multiplicity of their commitment to subjecthood and dialogue andréia and isabel envisioned and articulated a democratic form of building a movement and exercising power this article constitutes my effort to discern amid complex emotions activism and conflicts in the mmtr what i understand as a feminist and democratic vision in the way that they and other activists conceptualised both subjecthood and power this feminist and democratic culture of militancy forged by women who opted to stay in the towns where they grew up was radical in its twin identifications of gender and class as systems of domination that needed to be fought with grassroots activism and visions of an alternative future it was rooted in the daily life and practices of small rural towns and it grew out of a deep sense of subjecthood instilled by the liberation theology church and a growing conviction on the part of the young women that they were full human beings with dignity that they had rights and that they were protagonists in their own lives this conviction about being a person expressed as ser gente in portuguese took shape in mmtr meetings training courses marches and demonstrations over the years in large lecture halls and small group discussions the conceptualisation of a feminist and democratic culture of militancy described in this article emerged in the course of 15 years of research visits through multiple processes of seeing of patterns glimpsed principles enacted or spoken interactions performed or reflected upon this article asks how this impulse was expressed and what ramifications it had militancy as both feminist and democratic in part in comparison to other cultures of militancy described in this volume was articulated in dialogue as various mmtr leaders emma and i returned repeatedly to the topics we had been discussing over the years it also became visible when emma and i brought back writing videos and curricular materials based on interviews from previous visits and presented them for discussion in mmtr meeting spaces or when emma met with women individually to go over materials for accuracy a process that spurred further reflection what i present as a culture of militancy appeared as one thing amid many delineated most explicitly in splits within the mmtr itself and later in reflections on those splits to describe the feminist and democratic sensibility that developed among mmtr activists in maronata and andalinas i am revisiting interviews conducted in those towns between 1997 and 2018 4 this revisitation is informed by the cultures of militancy workshops out of which this special issue of radical americas has emerged and the issues that our discussions raised regarding vanguardism hierarchy discipline and gender on the left since the 1960s many of the movements described in this special issue insisted on unanimity in analysis and strategy among their members and many of those members accepted those pressures through selffashioning and selfsurveillance 5 at times too those profiled in this special issue resisted such pressures and ultimately broke with revolutionary organisations 6 these pressures to conform to one particular radical vision were heightened by contexts of military government and repression with the concomitant separation of militants from the society around them particularly in clandestine moments or exile 7 in the early years of the mmtr when brazils dictatorship was ending and a new constitution was being written and implemented the movements leaders and supporters also faced state and police repression as they would at other key moments going forward yet for the most part and in contrast to the experiences of others in this special issue the activism of these women coincided with a period of expanding democratic government in brazil that included significant if limited and uneven rights to free assembly and speech in the context of a leftist past of male vanguardism in brazil and elsewhere in latin america and in the face of hierarchical authority and unified strategies in other social movements mmtr leaders puzzled over how to foster subjecthood and correspondingly how much to try to fit everything together in confronting a world riven by class and gender practices from a more democratic and feminist position one open to multiple voices and forms of analysis have become more common among leftist movements in the 2000s than they were when the mmtr formed in the 1980s for example in the argentine piquetero movement indigenous mobilisations in bolivia occupy wall street the chilean student movement and estallido social and the movement for black lives at the same time the adoption of hierarchy and of unified goals and strategies and the reanimation of masculinist forms of vanguardism in the name of effectiveness continued in the last years of the cold war and into the twentyfirst century indeed in the late 1990s a group of mmtr leaders opted to ally the womens movement with the movement of landless rural workers and in so doing they tailored the mmtrs priorities and strategies to what they experienced as the msts more disciplined analysis and authority structure 8 it is in the context of this shift that andréia and others most directly articulated the democratic and feminist character of their militancy in relating life histories to cultures of militancy i combine a collective biography approach with a focus on particular critical experiences and tensions at the centre of individual womens activism and lives 9 through the interviews that emma and i did together we looked closely at the lives of six women who were leaders of or activists in the womens movement and explored in depth key tensions they carry with them 10 these tensions express the womens capacity to hold permit and examine consciously and unconsciously complex realities and interpersonal relationships at the heart of their culture of militancy in the next sections of this article i first set out the seeing and not seeing sensibility that enabled emma and me to discern the multiple simultaneous experiences at play in the lives of mmtr activists and correspondingly their capacity to hold this multiplicity in order to place the mmtrs culture of militancy in the context of broader challenges and changes on the left before and during this period i will then present a brief outline of shifts on the left away from vanguardism to a recognition of difference and multiplicity in brazil and mexico where i have also done ethnographic research in the final two sections of the article i will present the history of the mmtr and explore the mixture of autonomy and commitment to dialogue that developed and deepened among some of the mmtr activists as they envisioned a womens movement able to hold and foster multiple viewpoints strategies and emotions seeing and not seeing individual lives and social movements take shape know and sustain themselves interact and make impacts by holding multiplicity consequently a sensibility of seeing and simultaneity facilitates our understanding of cultures of militancy what i call seeing and not seeing means looking squarely at but also beyond and through the big things people habitually see and are primed to see such as institutions democracies movements economies viruses or borders by resisting habitual moves to coherence and making boundaries a seeing and not seeing sensibility works to both see and not see these phenomena so as to identify the multiple processes forces and representations that occur in through and around them out of which they are constituted and amid which they act 11 ludwig wittgenstein evoked such a sensibility with his suggestion of foregoing the construction of clearly delineated comparative categories with the advice that the observer not think but look in so doing one notices an aspect a pattern or starting point they have not seen before 12 psychoanalyst leston havens observes that the consistency regularity almost homogeneity we think we see in people is a product of our need to have one person before us a whole habitual creature when in fact socalled multiple personalities are really only the sharply etched version of what occurs in everyone 13 havens goes on to describe the approach of the analyst like that of wittgensteins philosopher or social scientist as they seek to perceive patterns out of complexity an evenly suspended attention he writes permits opposites to coexist in the mind i believe it is this unforced mingling that allows fresh combinations to appear and shed their light 14 in the course of participant observation and interviews with mmtr activists in maronata and andalinas over 15 years emma and i sought to suspend attention evenly listening and absorbing information as we asked questions bringing back transcriptions and video material from previous visits and finding stories shifting and deepening through reflection on our renderings of them and on our new questions out of this unforced mingling we began to perceive paradoxes and tensions that represented key aspects of womens experiences in the mmtr these experiences constituted parts of womens lives aspects of their biographies that they and we came upon in dialogue six womens interior experiences of activism in 2001 emma and i were present at the statewide convention where helena toneli was asked to continue in a leadership position in the mmtr but chose instead to accept the position of secretary of health in her small town of andalinas helena was a powerhouse a key and respected leader of the womens movement who could galvanise hundreds of women with her cry of mulheres however the other leaders of the mmtr would not accept her decision to work in government to improve health services as part of a centreleft coalition and they gradually isolated helena from being involved in strategising as a result helena felt acutely that she had two hearts in tension with one another one in the streets with the womens movement and the other in the institutions in contrast to helenas public and institutional roles sandra lorina spent long days producing milk and cheese on her family farm holding the paradox as she envisioned a new world through her participation in the womens movement while firmly tethered to this one in our interviews sandra constantly toggled back and forth between describing her daily life as it was and setting out convictions and visions completely at odds with ongoing family gender relations when we talked to sandra in her kitchen with her family around her she told us that she was looking forward to a time when her daughter edite was older and would be able to help her more it doesnt need to be girls who help she went on to say boys can help too but her boys only listen to their fathers demands for help on the farm not to their mothers requests in the house my husband is tired when he comes home from work sandra added he likes to sit on the couch and watch tv thats his place she motioned to her husband who was leaning back legs crossed and arms slung over the back of the couch he cocked his head at us grinned raised an eyebrow and nodded in agreement a different mindset a relatively egalitarian marriage and greater economic resources enabled andréia fornato the farmers union president to foster more congruence between her political and social vision and her daily life consequently andréia left the womens movement when it adopted hierarchical decisionmaking practices and allied formally with the mst and its international ally vía campesina but andréia mourned the loss of the movement as a source of inspiration and guidancea fountain she needed as she struggled with the meanings of power and of gender in family life and radical politics andréia wanted to be a steward of power rather than a leader who divides up power and uses it as their own power andréia said has to be understood as a space to speak and grow for a whole movement not for me as an individual when cristiele morolla went door to door in her tiny rural community to convince women to join the womens movement she encountered numerous obstacles from religious convictions to faith in pop psychology to the mens refusals to reconsider the safety of pesticides or to use condoms in the face of evidence of chemical toxicity and the dangers of sexually transmitted diseases in this her organising experiences paralleled those of isabel toneli cristiele dealt with the slowness of her organising work and the resistance she faced from women by gradually recognising how much there is working against women in the movement and confusing and complicating what they see to be true and she takes this recognition as her guide we know the world and we read the world cristiele told me and things go on from there isabel toneli and nara saroni were emboldened to live publicly as a lesbian couple and move in together in their small catholic town because of their immersion in the womens movement and the support for voice and autonomy for subjecthood it fostered years later however they found that there was no place in the movement they had cocreated with others to form a space for womens speech for them to talk about their relationship and they left the movement it was difficult to discuss their relationship in their family and town too although they continued to live in the small house next door to isabels sister and her family participating in a robust collective life as they experienced the paradox of silence amid speech the intimate experiences of these six activists suggest new categories for scholarly analysis and leftist practice in the final years of the cold war and in the twentyfirst century to understand what these women negotiate as activists and to support women in those processes means recognising that choosing activist strategies may engage multiple hearts and involve holding paradoxes on a daily basis and may include suffering in silence in spaces dedicated to breaking silence or as isabel described it finding some kinds of speech closed down at the moment that others open up activists may seek power as a space to be shared rather than as a resource to be gathered and wielded and they may read the world as they go literally and metaphorically door to door reaching only provisional analyses as they proceed andréia perhaps illustrated this provisionality when she struggled to show us the cassava which grows contingently taking unpredictable forms subject to context and conditions what might a left that acknowledges and builds on the sentiments expressed by these six women and the underlying pressures to which their emotions give voice look like through what processes and in what locations has such a left taken shape or been glimpsed encounters from vanguardism to multiplicity historians of the 1960s jeffrey gould 15 and eric zolov 16 observe that both the communist party left of the early and midtwentieth century and the cheinspired new left of the 1960s based their organising on male vanguards tasked with discerning and pursuing the most effective revolutionary strategies literary critics maría josefina saldañaportillo 17 and diane sorensen 18 find that the masculine and vanguardist underpinnings of such approaches wrote out difference first incorporating and then purging feminine identities and practices in saldañaportillos words guevaras representation of revolutionary transformation leaves behind a previously immature complicit consciousness for a fully formed collective one resembling a model of development that leaves behind premodern forms of subjectivity and agency for thoroughly modern ones both models invariably leave behind the ethnic particularity of indigenous or peasant subjectivity while carrying forward a racialized and masculinist understanding of fully modern revolutionary agency 19 in sorensens analysis this occurred in the context of a sexualising of power that made revolutionary leaders not only the repository of superior male humanness but also capable of inspiring intensity of feeling that reverberates through the body politic 20 sorensen discerns a different vision of political activism in the reportage of mexican journalist and novelist elena poniatowska on the 1968 massacre at tlatelolco 21 in poniatowskas representation of one of the paradigmatic repressions of the 1960s and early 1970s which led directly to the formation of mexicos focodriven clandestine left sorensen finds a deliberate attempt to explode unity and to relinquish a totalizing vision while ushering in a disparate group of witnesses whose testimony configures a mosaic of splintered pieces by allowing different voices to speak she observerauthor poniatowska constructs a decentered representation of community anchored in plurality 22 the reader of poniatowskas text which she produced by piecing together taperecorded interviews is immersed in the microstories of the everyday experience of 68 as if through fragmentation and polyphony it became possible to reconstruct the meanings of politics in everyday life 23 poniatowskas text anticipated a sea change in the politics of the radical left in latin america one apparent two decades later in the culture of militancy of some members of the mmtr with their emphasis on subjecthood and dialogue 24 poniatowska perceived and recognised multiple voices in an event that could have been told monolithically as one of the founding repressions of 1968 and the ensuing decade 25 andréia too created her political vision from a mosaic of splintered pieces including family and community experiences the provocations of liberation theology priests and nuns a ferment of socialmovement activism in the final years of military dictatorship and feminist insights circulating between urban sites and the countryside and andréia like poniatowska herself did not reduce these experiences to a totalising vision rather she infused radicalism with agency and emotion drawing on these approaches i hope to produce something similar in this article a mosaic of splintered pieces from a disparate group of witnesses to represent a community anchored in plurality while the 1970s is widely perceived as a decade of military repression and the literal disappearance of the left 26 the origins of a more plural and indeed more democratic practice of leftist politics can also be located in the experiences and innovations of grassroots encounters during the same and subsequent decades among radical priests indigenous people feminists and workers in the jungles and shantytowns of mexico and brazil as well as numerous other locations the visions and practices developed in these encounters prefigured indeed hammered out new forms of leftist subjecthood and practice in the americas it is through this lens that i view the organising and meetings of the mmtr and i will recount some of those experiences of encounter and innovation here this innovation developed for example with the turn to ethnicity and elections that occurred in the 1970s in the southern mexican city of juchitán where radical zapotec students encountered their own pueblo and past to produce a visionary politics that diverged sharply from the rest of the latin american left 27 rather than reject indigeneity as premodern to be replaced with the identity of campesino as much of the latin american left was doing at the time the juchiteco students fused the zapotec cultural practices among which they lived long shaped in part by zapotec elites with a classbased movement of indios and they furthered that indigenous movement by competing in elections for municipal and then statewide office a practice rejected by virtually all of the mexican grassroots left at the time 28 but reflective of electoral competition locally as it had evolved in the course of the twentieth century in that way they saw beyond the prevalent classbased analysis of their time to envision as the mmtr leaders did new forms of subjecthood and political practice pivotal moments in the development of a religiously infused subjecthood as well as the rejection of vanguardism occurred among mayan indians in the lacandón jungle of chiapas and among residents of the shantytowns of são paulo brazil in the new settlements of the 1970s in the lacandón jungle priests influenced by liberation theology came together with indigenous maya setting up new communities and with clandestine leftists who had left mexico city after the 1968 massacre at tlatelolco to start a revolution in the countryside 29 the zapatistas in their theories and in the fierce contestation that occurred among different mayan groups on the ground before and after the 1994 rebellion 30 navigated a world of both pluralism and fragmentation and struggled to develop and implement a politics that balanced dialogue and unanimity in productive ways at much the same time mmtr activists grappled with how to navigate disagreement some of them choosing hierarchy and unanimity others reaching for dialogue and multiplicity in the 1970s in são paulo liberation theology priests encountered women in mothers clubs on the urban periphery as well as metalworkers in the citys steel and automobile industries members of each of these groups began to play multiple roles as priests ejected the charity ladies and worked with women to create new kinds of mothers clubs along with organisations to protest the cost of living and members of christian base communities ran for office in union elections 31 the interactions of priests workers and shantytown dwellers again a diversity of groups produced movements for economic rights internally democratic industrial unions and ultimately the workers party which insisted on a different view of what democracy should mean in brazil 32 furthermore the union leaders and the massive strike waves they led in 1978 and 1979 created a new more equal relationship between workers and leftist intellectuals and politicians as workers were no longer willing to leave the act of interpretation for others 33 the women of the mmtr distanced the movement from the church when the very priests who had encouraged the women sought to limit the reach of their activism they too were no longer willing to leave the act of interpretation to others during the same time middleclass feminists encountered workingclass women on the periphery of são paulo 34 and subsequently in the hemispherewide encuentros that shaped latin american feminist movements 35 these encounters also included women returning from exile having interacted with european and us feminisms in the new spaces created initially by the church and the economic movements poor and darkskinned women on the urban periphery turned the expectations of largely white middleclass feminists on their heads by speaking about gender relations in families health and womens bodies and sexuality topics that middleclass feminists had thought would be taboo in poor neighbourhoods feminist political practice then gave rise to new inductively derived theoretical insights 36 as women took new positions in the formation of the workers party the debate about the brazilian constitution and government policies on daycare and womens health in a similar way mmtr activists played key roles in political party debates and electoral strategising as well as in municipal government and the development of alternative organic agricultural models encounters among different individuals groups and political theories which occurred in jungles shantytowns and union halls thus transformed leftist analysis and practice from the 1970s to the 1990s these encounters rethought the nature of indigeneity in modernity and protest assimilated elections as focal points for radicalism built radicalism from lived religion and new religious theorising repeatedly rejected vanguardism stimulated a wide range of activists to try out different roles in fostering social change and challenged and revised leftist and feminist orthodoxies by heeding peoples daytoday experiences and convictions as young women in southern brazil encountered conduits of these ideas and experiences in the form of liberation theology priests workers party activists and urban feminist advisers they engaged with all of these ideas some of the women took them up with gusto the history of the mmtr background the church and the social movements the mmtr 37 was formed in 1986 in a rural region of southern brazil where women had few economic rights or official documents did not hold public positions in the church unions or government and could not speak freely within their families or leave their houses without their husbands or fathers permission the women who founded the mmtr came from poor lowermiddleclass andor landless families whose livelihoods had been threatened for almost two decades by agribusiness and the mechanisation of agriculture that characterised the rural development model promoted by brazils military government 38 the womens political coming of age followed the formation of the workers party and drew on their own and their parents organising experiences in the workers party and rural unions the movement itself took shape during the tumultuous years of brazils transition to democracy in 1985 and the subsequent national process of writing and implementing a new constitution the political ground on which the mmtr founders strategised included the legacies of both military repression and the countervailing processes engendered by that repression in the context of cold war fears of communism in the 1970s brazils military government fearing the explosive potential of class relations and poverty in rural areas had established a legal framework for rural unions expecting those unions to largely remain under official control 39 these were the unions in which andréias father and others had fought with some success for accountability and responsiveness and where andréia first learned the tactics of political organising in the same decade motivated by military violence rural poverty and attacks on the church itself the catholic clergy in southern brazil turned increasingly to liberation theology as a means of bringing religion to bear on pressing social issues 40 many of the women in the womens movement began their lives of activism in the pastoral da juventude after priests or nuns came to their houses to convince their parents to let them be educated and to be introduced to analysis of the socioeconomic realities of the world by the priests and nuns themselves when parents were reluctant priests or nuns stayed for dinner played cards and if parents did not change their minds came back the next week to make their pitch again in interviews women recounted the places to which the priests and nuns took them to see poverty and deprivation worse than their own women in their thirties remembered their travels through the countryside with activist nuns who insisted on identifying and challenging the subservience of women and expressing their religious commitment to developing a deep notion of subjecthood and an ongoing practice of luta if the nuns taught the women about subjecthood about being worthy of dignity and acting as protagonists in their own lives what the young people learned about the tactics of activism came primarily from the social movements burgeoning around them from the antidam movement fighting the destruction of towns by flooding to the msts land occupations 41 the young people women and men alike formed these movements and were formed by them in an explosion of organising and making social connections radical imaginings of structural economic change and mobilisations on the streets however many women activists saw womens rights and needs relegated to the sidelines in the growing land antidam and union movements in the region in response women in maronata andalinas and other towns in the interior of rio grande do sul formed the mmtr choosing to designate the movement as one of women workers including women who worked on small family farms to emphasise the economic identities and rights of rural women as well as the challenge they mounted to the broader development model process from home ground a womens counterpublic the mmtr activists were women who did not want to leave and for the most part never left their towns and families of origin they sought from their home ground to reform the personal community and economic relationships amid which they had grown up and come of age including making the land productive and farming practices ecological and sustainable even as the women speak of close relationships with their families as well as admiration for their fathers many of whom were union activists in the 1970s they clearly identify the control exercised by their fathers and the silence and subservience of their mothers in a story repeated in one way or another by many of the women jussara lambini now with a masters degree in sociology tells of her fathers refusal to allow her to attend school or womens movement meetings and remembers what it felt like to go anyway i did that walk crying in the dark the cold the rain okay i told myself im going because i want to go to that meeting because its important today jussara who lives in the nearby city of ralindo where she works as a professor and consultant and coparents with her husband often visits her parents in the house in the nearby countryside where she grew up these young women were fighting to reform gender relations and economic structures not only in their societies but also in their families of origin and their own nuclear families the movement formed by the young women during the last years of the cold war provided an intense sense of belonging in a feminist culture of militancy in close proximity to daily rural life its in the movement that we feel valorised its there that we feel we can do something by creating a womens counterpublic 42 manifested in demonstrations and especially in a wide range of meetings conducted over the course of 15 years the womens movement transformed individual women and enabled them to simultaneously fight for new laws and change their own lives its like a light switched on the mmtrs early campaigns from the mid1980s to the mid1990s involved mobilisations related to the writing of brazils 1988 constitution including pensions and maternity leave for rural women and political organising and protest to bring about the implementation of that constitutions provisions the activists secured pensions for rural women frequently accompanying their mothers to the bank to claim a right that their parents generation had considered unattainable and maternity leave for themselves and their experiences in the movement enabled the young women to develop more egalitarian relationships with male partners to form samesex relationships to promote organic agriculture on their land and to assume prominent leadership positions in churches agricultural cooperatives unions and government offices in their communities in the words of cristiele morolla before the movement we didnt know how to change our history with the movement active around them they learned and they made changes in interviews about the mmtr activists spoke repeatedly about the ways in which women experienced subordination and the reasons why this was unjust and needed to be changed like jussara each of them had to leave their fathers home in one way or another to catch a bus to go to a movement meeting or to school they fought to break the silence with dialogue in multiple spheres of their lives and acknowledged how difficult it was to initiate and sustain this something for which theyd had no training at home at work in church or in other social movements in meetings small and large they presented and absorbed masses of information and initiated discussion in the movements second decade they formed alternative womens pharmacies as locations of physical and psychological healing based on dialogue the goals of activism were simultaneously to change the rural economy and to enable women to ser gente to truly be people accorded dignity and capable of acting isabel and her partner nara talked of moving in together as lesbians and building a house next door to isabels sister and brotherinlaw and their two children in so doing the four adults forged a new kind of family sharing meals and childcare one of the leaders of the womens pharmacy in andalinas said i felt like a person even more of a person mais gente ainda as they came to understand themselves differently the women chose whether and how to fit everything together in one radical analysis and movement or not fit everything together in what i am calling their feminist culture of militancy meetings cultures of militancy can be multiple this culture of militancy developed in a variety of demonstrations and meetings including workshops for alternative womens pharmacies local and statewide womens movement celebrations for international womens day protests in the streets and assemblies and pilgrimages involving a range of rural social movements the beliefs and practices that constituted this counterpublic 43 involved an array of diverse and often contradictory activities including analyses of brazils economy presentations on rural health and environment singing and ceremonies frank discussion of the personal pain of depression and silence planning for events and protests and selfhelp strategies the meetings could suddenly change direction from long histories of the effects of capitalism on brazil to pageants of barechested men and pregnant women carrying pure seeds evoking a gardenofeden future from detailed analyses of the effects of pesticides on local ecologies and health to exhortations from a psychologist that women learn to be better happiness managers in their families from physical exercise to relieve stress to frank accounts of rural isolation women took all of this in sometimes they commented on gender in a direct hardhitting way i was a slave to my husband for 30 years thank god he left now when i want to leave the house i leave or in a discussion about gender and sexuality were afraid that our husbands will love us less if we dont serve them properly were afraid of being useless and less loved some men after 40 years of marriage dont know where the towels are kept the mmtr meetings demonstrate that cultures of militancy can be multiple they are uneven and creative they may reinscribe harms they may open or shut down pathways or voice they are acts of simultaneous holding we cannot understand what cultures of militancy are or how they play into broader politics by seeing primarily what a movement says its culture or meaning is or what is most prominently performed or what we as researchers came to it to study using a seeingandnotseeing sensibility we need to perceive multiple words and performances from the ways in which women occupy space in the room to what makes them move forward in their organising we need to not see the movement as a bounded and coherent entity so as to sense and develop an ability to make sense of the strands forces and lives that run through it and out of which it is constituted decades from unified campaigns for rights to disagreements over goals and strategies in the first 1012 years of its activism the mmtr focused on securing economic rights for rural women in the context of a trenchant analysis of gender relations and genderbased inequality and subordination 44 during these years the movement attracted an expanding and diverse set of supporters of a variety of ages young women and their mothers alike 45 it changed the world in tangible personal cultural and economic ways and offered compelling visions of an alternative future notably the womens movement secured pensions maternity rights documentation and credit for rural women these were revolutionary gains in a society where women had been economically marginalised controlled by their husbands unacknowledged by official documents and silenced in the movements second stage from the late 1990s to the early 2000s the unity of purpose that had characterised the movements early years frayed as mmtr leaders struggled over what direction to take once the movements first goals had been achieved should the mmtr form the womens component of a classbased radical project tied to the battle for land and to political strategies of direct action should the rural womens movement focus on women and gender by addressing healthcare family gender roles and sexuality domestic violence and womens pharmacies or should it lead a democratic and community project based in unions and municipal government in the end the activists came to occupy a set of locations of which the formal movement became only one part in which women took on new roles in their communities in terms of jobs and politics and furthered their gender and class goals as well as their personal trajectories in different ways however they were not able to contain these different commitments and strategies in one movement or to envision a horizontal networked set of movements and initiatives beginning in the late 1990s a succession of mmtr leaders decided to leave or were pushed out of the movement while those who remained in the movement headquarters in the provincial city of ralindo fostered increasingly close ties with the mst in this process of exclusion and withdrawal the women whose culture of militancy i am describing left the movement control of leadership positions by the mstaffiliated group was achieved through formally democratic procedures but without the robustness of democratic politics or a commitment to inclusion and difference a feminist and democratic culture of militancy the mmtr like the innovative encounters in the last two decades of the cold war described above grew out of the unusual alliance of different political and social actors such as nuns and priests union reformers radical leftists feminists and young women in union halls church meeting rooms and marches and demonstrations in the countryside and in the state capital the personal interior experiences described in the section six womens interior experiences of activism in this article together with the meetings described above shaped the culture of militancy of the women activists in andalinas and maronata in ways that make it both feminist and democratic this section will examine this culture of militancy directly through the ways in which women themselves understood and held their experiences in their examinations of subjecthood decisionmaking power and the emotions and capabilities of being a movement the activists in maronata and andalinas like andréia vanessa isabel helena and jussara help us to see issues and tensions that arose in earlier clandestine movements of the cold war period in a new light they challenge masculinist and vanguardist approaches by asking how do you know and how do you decide they problematise tensions between activism in the streets and the institutions by asking where do you act and they radically reformed gender roles by asking who acts and how as this section will show the life histories of particular women make visible the forms of tension and holding that constitute this culture of militancy in talking about their lives these women combined understandings of selfhood and collective politics vanessa saltara equated leaving home and entering the space of movement meetings as the beginning of thinking for herself for vanessa the womens movement was a place of education like a university and a pathway for women both individually and collectively to occupy new spaces in society she and others credited the movements campaign to secure documents for rural women as a source of happiness in two senses in having their existence recognised and as a basis for legal rights at womens movement meetings information plentiful often unfiltered and contradictory provided at times for hours on end was presented and received in our interviews andréia spoke of pleasure of a right and desire to take pleasure in her life of the fact that she was an activist among other reasons por gusto andréia also recounted her combined determination and patience to achieve the position of first woman president of the maronata farmers union once accepting being pushed aside and biding her time but then insisting on taking her turn the next time when she talked about heading the union which she characterised as a male space she described doing it in a womans way isabel and nara said that it was the space of voice and acceptance created by the womens movement that led them to act on their attraction to each other and move in together cristiele explained how the movement functioned for her like the turning on of a light switch leading her to return to the countryside to embrace sustainable agriculture and continue organising for the womens movement as she undertook this work she shared household tasks with her husband who for his part did not believe that men should be waited on by women these are all statements about selfhood and collective politics the way one shapes the other as sorensen observed in her analysis of poniatowskas texts through fragmentation and polyphony it became possible to reconstruct the meanings of politics in everyday life 46 this sense of selfinformation came out of the womens family histories the young womens sense of themselves grew out of their fathers work to make local unions genuinely representative of farmers interests rather than instruments of government control even as they ran their households in an authoritarian fashion and out of their mothers capacities to withstand silencing and later join their daughters in protest marches for womens economic rights it grew from having to fight to leave the house to attend meetings but leaving nonetheless in ways to which i gained access only indirectly the womens parents appear to have nurtured their daughters independence albeit in constraining ways at least they raised daughters who could assume independence as the world changed around them and who could not only leave walk down the road in the rain to attend a womens movement meeting but return the church deepened and made this subjecthood explicit by bringing individual young people into the youth pastoral work and taking them to see and then theorise the world around them as they were taught to understand themselves as subjects the liberation theology priests and nuns were teachers and advisers who accompanied the movements but did not generally seek to determine their paths in a recognition of collective subjecthood this rootedness of local politics in personal and collective biographies made the splits in the movement which arose in the late 1990s and early 2000s all the more confounding to mmtr activists between 2002 and 2004 after the womens movement headquarters had formally allied with the mst and vía campesina andréia and vanessa spoke to me about their uncertainty over whether and how to wage a battle within the womens movement to take it back by which they meant bringing the movement back under the control of women committed to its autonomy and to holding multiple ideological and strategic positions within one movement one of the early advisers to the movement a priest and educator worked with them to formulate pathways by which vanessa andréia and other founding members of the womens movement might do this either through dialogue and elections to leadership positions within the movement or by negotiating an explicit space for womens activism within the farmers union 47 it was in discussing the need to reclaim the movement an effort that never took place that vanessas and andréias democratic commitments became clearer each of them wanted more planning to occur at the municipal level closer to womens daytoday lives rather than primarily in the state headquarters which was linked in turn to national and international movements and subject to their priorities each of them wanted the womens movement to support both vía campesina the international peasant movement and the less radical locally rooted farmers unions vanessa wanted mutual support but the womens movements current leaders she observed never supported the unions vanessa and her husband alessandros support for the unions grew out of their lives as farmers who needed to work the land and milk the cows daily and who had grown up in their small towns their affiliations and schedules differed from those of mst supporters many of whom lived in acampamentos pressuring and waiting for land expropriations to be carried out and to construct new communities on the redistributed land the difference in the availability for and the tactics of protest lies in the manner of working it was also the case that the difference lay in competing political theories and visions should moving forward collectively mean fighting for the reform of existing institutions such as negotiations carried out by farmers unions or a radical break with these institutions through actions like illegal land occupations in practice there were overlaps in these pathways in commitments to organic agriculture relations with government ministries and programmes and daily agricultural work but activists did not find a way to use these commonalities to bridge the competing strategies and goals that divided them furthermore as alessandro said vía campesina has a very authoritarian way of running things which is how many local activists experienced the global movement vanessa defined democracy for those who disagree in this way everyone has time and voice vez e voz to be able to decide together to find an alternative the portuguese vez e voz might also be translated as the opportunity to speak although that does not capture the space and subjectivity vanessa considers essential to democracy what is lacking for us is to sit down and converse because in truth we are not being democratic we need to sit at the table and put out there for everyone what is happening they set out their problems and we ours and we reach an agreement for andréia this would have meant making sure that the womens movement had its own goals and struggle from that position depending on the strategies developing in particular moments you ally with vía campesina or with the unions i dont think the womens movement needs to be always with one or the other but rather to decide at particular moments what would best serve the goals of the women in the movement the women who gained the upper hand in the womens movement leadership in the late 1990s and 2000s rejected this sort of autonomy in the interests of forging a unified national leftist peasant movement whose central leaders could make strategic decisions that would be followed by affiliated organisations both in moments of crisis and for the long haul these leaders also rejected participating in the institutions by which they meant the official political and administrative organisations of government like political parties elected offices ministries and departments similarly under institutions they included the daily tasks and leadership roles of unions because of the unions reformism and their origins in government policy and in law as well as their formal recognition by state authorities the leaders of the womens movement rejected these forms of participation out of the conviction that positions in government would absorb and coopt activists and weaken radical goals a process that arguably occurred in the course of the presidencies of luiz inácio lula da silva and dilma rousseff each from the workers party exploring the implications of this view in 2007 i pressed two leaders at the womens movement headquarters in ralindo on the question of what andréia calls autonomy and helena flexibility elisabete a nun had long been involved with the womens movement and janaína remembered taking notes for her mother at movement meetings when she was a child janaína had also studied political analysis and leadership at an mst school my feeling that i could pose this question to them and their offering of a frank answer represented a level of trust that it had taken years to build with leaders in the womens movement headquarters just before this conversation emma and i had shared with elisabete and janaína video photographs and text showing the curriculum we had developed for us classrooms on the mmtr based on interviews we had done in 2004 we also talked about one of the early leaders of the movement whom emma and i had interviewed and incorporated into the curriculum and who had recently passed away in posing my question about autonomy i listed the many women we had interviewed who were no longer active in the statewide movement even though they continued to support movement initiatives and other womens campaigns in their towns each of these women including andréia vanessa helena and jussara had opted for the institutions in one way or another taking leadership roles in unions or local governments at the same time that the leaders of the womens movement had chosen to ally with the mst and vía campesina with their emphasis on protest in the streets and centralised decisionmaking 48 more than once emma and i were shown photo albums filled with snapshots of many of the women we knew all together at weddings baptisms graduations and protests now they gained news of one another from a distance and acknowledged this with nostalgia and a deep sense of loss elisabete and janaína explained that to believe in unions and local governments is a very different thing from believing in a project of radical social change and if you understand that janaína went on then you understand that you have to make a choice in response i said it sounds like you were willing to lose key leaders so that you could join with a larger and more radical political project janaína agreed its about whats fundamental the character of the movement janaína and elisabete went on to acknowledge that women didnt just leave the mmtr for personal reasons owing to their life trajectories as had often been claimed but were forced out in various ways and that the decision for the womens movement to join vía campesina was a political one that had both benefits and real losses in saying this the two women put into words something that had long been understood by the women who had been pushed out but left largely unacknowledged the method of making decisions and exercising power that janaína and elisabete described reflects the stances of the older vanguard left in brazil and latin america and the conviction on the part of past leftist militants that the leaders of a movement were those best suited to discern the pathways for radical change while this might well involve ongoing communication with a movements base with shifts in strategy resulting from this communication effective political struggle meant the leaderships discerning and enforcing a unified viewpoint and strategy furthermore communication with the base could become increasingly difficult as activists faced repression clandestinity and exile historian james green in his biography of the leftist militant herbert daniel and the clandestine left in brazil in the 1960s and 1970s locates the origins of this position in the activism and theorising of che guevara and régis debray which electrified young brazilian activists in those decades and spurred them to overcome their social backgrounds to advance a centralised struggle 49 andréia the union president who had introduced us to her garden embraced and learned from her social background in a way that led her to understand power differently she regretted having allowed herself to be pressured to leave the womens movement leadership i dont know why i left why i didnt fight back andréia told me in the union hall i didnt see what was coming and i didnt know how to make the right arguments so i opted to leave but despite her success in leading the farmers union andréia saw how much women needed the space of a womens movement so what will we do she wondered we are the mmtr so why do we have to create another womens movement why isnt this one ours two years later having experienced more of the successes of leading the union and the costs of no longer being part of a movement andréia went further i should have fought back other women would have supported me the movement is ours too andréia knows that political power like womens power in their families has to be understood and handled with care in her personal life she refused her mothers submissiveness and her fathers linking of domination at home to progressive politics outside still she stayed in her home town and fashioned a different life for herself as an activist andréias husband respected her political work and shared her goals and they brought their sons up with a new openness about gender roles in politics andréia insisted on the value of individual voices and democratic decisionmaking she opposed the mst because of its rejection of institutional paths to political change and because as she saw it decisions were made by leaders and then handed down to everyone else what is power and how do you exercise it andréia wondered in her view the leaders of movements that are run from the centre want to divide up power and use it as their own to command others but she wanted to be a steward of power i cant be in the same place forever other people are going to come to take my place and power too it has to be understood as a space to speak and grow for a whole movement not for me as an individual this understanding of power reflects what was learned in the jungles and shantytowns in the 1970s and 1980s then spread widely via liberation theology priests and nuns academics and political advisers to social movements urban feminist movements and nongovernmental organisations and activists in new leftist political parties all of these groups interacted with the activists in the womens movement from the mid1980s onwards these interactions fostered a fundamental shift in the militant cultures of latin americas left a shift that developed out of experiences of encounter and translation as described in the section encounters from vanguardism to multiplicity above years after she broke with the statelevel womens movement andréia expressed deep nostalgia for the way in which the movement had served as inspiration and guide we women need a source for clear thinking and for us the movement was that source she explained and today we dont have that anymore without the movement in her life andréia observed she finds herself taking missteps or compromising when she should stand firm because the questions in our lives are so profound that you need constantly to be analysing and rethinking them or in an instant you find yourself doing things that just a short while ago you wouldnt have done there is both certainty and uncertainty in andréias conception of power she knows what power should not be in terms of centralised authority and the exclusion of voices she knows as well that what power is how it is held and what it is used for is worked out in process on the ground and she knows that power is shaped in anisias words by the whole process of gender these conceptualisations of power come out of occupying a place or position temporarily making the very notion of position fluid and contested to engage in this working out of power one needs the openness and creativity of being a movement which animated the early years of the mmtr for andréia as for other women the mmtr at that time was a source a spring or fountain that nourished them provided them with ideas and guided them it was this collective spring the result of having forged collective action together that provided ongoing nourishment not a particular theory or reading of political circumstances alone helena too expressed uncertainties at the core of activism inherent in her two hearts at an international womens day meeting in the state capital of porto alegre in 2002 women from several different rural social movements gathered after the daylong lectures on the brazilian economy with women holding on to the microphone to tell their stories and the pageantry of socialism as a paradise of harmony with nature olivio dutra the governor of the state of rio grande do sul at the time arrived to address the gathering in the enormous gym ringed on the inside by the concrete bleachers where the women rested and slept and on the outside by the tents where they cooked and ate and gossiped at this moment helena introduced the governor simply we need to move forward so that the state will fulfil its promises so that social movements will achieve their place and know where power is and so that gender will be taken seriously and be more than a discourse this eloquent introduction at the centre of a highly orchestrated meeting spoke of helenas skill the same skill she had used to impress priests with her diplomacy in the youth pastoral work many years before she placed before the governor the essence of the womens movements hopes and demands but when i thought about it later i realised that these remarks struck a surprisingly openended note what is the place of social movements and where is power helena like andréia knows how complicated and dangerous power can be she knows that as a leader of the womens movement she supported the majority view and the ousting of others and that she in turn was marginalised by the movements other leaders when she opted to run the health department and work within the institutions now helena agrees with andréia that there shouldnt only have to be one viewpoint in a movement that there should be what she has come to call flexibility andréia calls it autonomy and connects it to the sense of self the mmtr fought to develop in women since its inception what she calls o meu eu andréia left the womens movement the moment she felt that self to be denigrated though now she thinks she ought to have fought back to make a place for voice and dissent by the mid2000s the possibility of one womens movement containing multiple women projects views and strategies was gone but by then as well many women could envision a flexible kind of movement a movement of deeply connected yet autonomous individuals some of them doing battle within the institutions of brazils democracy in the health departments and schools the city councils and town halls and the political parties and electoral commissions and others outside of them in the neighbourhoods in the land occupations and the pilgrimages for the land outside the doors of government offices in the alternative pharmacies and on the streets one womens movement holding and enabling different viewpoints strategies and emotions 50 and what happens when gender moves beyond discourse when challenging the practices resulting from gender inequalities moves to the centre of politics and daily life as helena suggested to the governor like cristiele and isabel and the women at the pharmacy helena knows how hard it is to go door to door literally and figuratively to try and convince women to see the world in a new way she has seen over the years how hard it is to change mens attitudes and beliefs their refusals and acts of violence she also knows that at particular moments dramatic public mobilisations can press legislators to turn womens economic needs into legal rights like andréia helena knows that shes not sure what she means when she imagines a future without the constraints of gender who would people bethough she is sure that women should have a voice and the power to make decisions in every domain of their lives and like the women in the pharmacy helena knows the pain and hardship of womens daily lives the intractability of gender roles inside women themselves and all around them and the reality of hardwon change helena and the women in the rural womens movement are fighting for more than rights in any conventional sense bringing gender to the centre of politics embodying seeing and not seeing the whole process of gender means you have to grapple day in and day out with what it means to change and fail to change those you know and love if you stay in your home town and fight for equality and a voice for women you are fighting to redeem the past as much as to create the future to reach what might have been and might yet be 51 in her lifelong commitment to luta helena is fighting in encounters in church basements and union halls among local women interacting with outsiders for a better way of living she cant define and a way of holding power she has not experienced in our interviews with them conducted mostly in 2002 2004 and 2007 but spanning the period from 1997 to 2018 the womens movement activists in maronata and andalinas expressed uncertainty about gender and power and wondered aloud about choices theyd made regarding the mmtr reflective about these choices they recognised the ambiguities with which they grappled in choosing to form a movement as a path for radical change isabel and nara who had moved in together as a lesbian couple identified these ambiguities in the silence of not only others in the movement but also family members while they lived together openly their repeated efforts to get the movements newsletter to discuss lesbianism brought no response when they spoke about their experiences as a lesbian couple with family members they were met with openness but found that silence closed in around them immediately afterwards it was up to them to break the silence again if they wanted to continue the conversation in discussing the daytoday process of organising of speaking with women in their houses and workplaces about the weight and danger of gender inequality cristiele and isabel were frank about the contradictions of gender and power they were up against even as they could not quite understand them they related with both distress and humour womens attachment to the prescriptions of a male god so that they distanced themselves from isabel who did not hold these religious convictions they described women who understood the dangers of pesticide use and who opposed the cultivation of genetically altered crops but then turned away from the womens movement when their husbands refused to budge on these issues cristiele and isabel recognised the appeal of selfhelp experts who focused on using inner resources to foster happiness even though for the two of them the cause of many household difficulties came down to the price of milk when i first heard cristiele and isabel describe and laugh about these ambiguities and seem to mock womens acceptance of irrational constraints and selfhelp strategies i thought it demonstrated a lack of empathy and imagination over time though i realised that they knew exactly what they were up against in cristieles words we know the world and we read the world and things go on from there furthermore in reading the world they simultaneously distanced and did not distance themselves from ordinary women in the movement and in their towns womens movement leaders in maronata and andalinas ran the health department where they attended to individual womens needs daily they established a shop right in the centre of town where they sold organic fruit and vegetables and other products produced by the women themselves they visited and talked with farm families for union campaigns and they worked cleaning houses and in agricultural processing plants with other women to support themselves in their conversations with us as in their closeness to womens daily lives leaders of the mmtr recognised complex and knotty places of pain oppression and shame and the way these experiences and emotions entered into activism it wasnt just that these experiences constrained activism but rather that they were the stuff of peoples lives of their subjecthood and recognising and knowing this subjecthood deeply in its places of complexity and repetition underscored for these women the necessity of a politics that was feminist and democratic so that if sandra could not unravel the gender constraints of her marriage and family or leave her physically abusive husband the movement would hold sandra movement activists fostered her capacities as a leader and helped her to get her husband to aa rather than condemn or ostracise her for weakness or some sort of hypocrisy in not being able to put her past behind her and in a meeting in andalinas the activists would not only grapple with what a feminist practice of selfcare might look like teaching and reteaching 300 women about recognising stress and finding space in daily life for conversation they would also create small groups in the larger room where women could attempt to put into words the abyss of silence pain and death that they usually confronted alone on their farms and in their families in the end the womens movement activists in maronata and andalinas focused on dialogue as a goal not just a process in a discussion that followed skits at a womens pharmacy workshop many of the women said that there wasnt dialogue in their families today dialogue lisete observed is when people make exchanges i say what i think and you say what you think that can be a negative thing fátima countered if we disagree thats okay lisete answered discussion isnt always calm there can be arguments we have to experiment with dialogue in our own families another woman suggested leading terezinha the facilitator to add its not easy to know what dialogue is you have to learn it as you get older listening to these observations about dialogue i realised that when women in the movement think about challenging submission and silencing they envision not only equality or independence but also dialogue to gain a voice and exercise that voice through dialogue to work out what words to say to negotiate with your husband about leaving the house and to hammer out a common strategy in a womens movement filled with strong and principled disagreement these were daunting tasks for women in the movement in the womens pharmacies they pioneered the activists spoke a language of radical analysis and compassionate care articulated through herbs massage and dialogue in their discussions of autonomy and power they recognised and grieved for their own inability to hold onto or reclaim their place in the formal movement these women indeed read the world and acted individually and collectively in ways that were necessarily partial and uneven the early years of womens movement organising took place during brazils transition to democracy with the significant if uneven protections for assembly speech and protest that afforded the movements big early successes in securing pensions documents and maternity leave gave way to multiple locations of activism in complex institutional and directaction spaces political and movement relationships splintered and families and farms demanded attention and financial resources in womens movement meetings and in their personal lives activists experimented with dialogue internally and with others step by step over the years uneasily grappling with genderbased inequality and harm these are the provisional positions of democracy and feminism in this context the women in maronata and andalinas and other locations of womens movement activism in the region developed a culture of militancy that came to involve taking stock exercising power with an awareness of others and sharing it drawing on a spring rather than a dogmatic political theory and building uncertainty and selfawareness and irony into their fervently held positions 52 their rootedness in place with its connections to swirling currents of liberation theology and leftist organising enabled the young women to create a movement that served in its early years as a space for experimentation inspiration and guidance two decades later the same grounding in daily life even as it sensitised them to the ambiguities of existing social relations and emotions rendered them too engaged in multiple arenasfrom unions to health departments to womens pharmacies from families to farms to schooling and jobs to fight to take back the movement and make it autonomous yet their struggles and successes along with their understanding of limits and alternative possibilities remain supremely relevant to the present in times of covid19 and resurgent authoritarianism in democracies as activists and leftist governments seek new ways to balance subjecthood and mobilisation and to engage with and transform the broader societies of which they are a part notes 1 the names of all individuals and towns in this article are pseudonyms 2 the mmtr was colloquially known as the womens movement and i will use these terms interchangeably in this article in the early 2000s the name of the mmtr at that point a national movement was changed to movement of peasant women almost all of the women discussed in this article rejected the name change and continued to use mmtr to describe their local activities as well as the movement as a whole for this reason i use mmtr throughout this article 3 at the time of these interviews maronatas population was approximately 14000 andalinas about 38 miles away had about 7000 residents 4 i first interviewed activists from the mmtr in 1997 and at greater length in 20012 my research on the mmtr with my daughter emma began in 2004 and continued through to the publication of our coauthored book about the movement sustaining activism in 2013 our first joint research trip which took place in 2004 when emma was in high school involved doing video interviews with mmtr activists for a curriculum on social movements in brazil and the united states that we designed for middle and high school students and that emma taught in her high school in 20056 we presented this curriculum to teachers in workshops at the latin america centres of the universities of harvard duke california san diego and brown as well as in other forums in 20078 we brought written and video materials documenting our work back to the women in the mmtr in 2007 and during subsequent visits presenting our work at movement meetings to individual women in their homes and in the movement headquarters in ralindo while this article is based on this largely pre2013 work including interviews and the book its analysis and writing grew out of my participation in the cultures of militancy workshops and were conceptualised and written by me 5 pedemonte student colectivos in the ussr 6 rom martians in the favela véliz estrada radicalisation and political crisis 7 rayas clandestinity and militant culture 8 for a sympathetic analysis of the mst that covers the movements origins strategies and successes see mançano fernandes a formação do mst no brasil for a strong and controversial critique of the movement including its internal practices see navarro the brazilian landless movement for the most ethnographically detailed and politically balanced work on the mst see wolford this land is ours now for background on vía campesina see borras la vía campesina descriptions of the mst as centralised andor authoritarian which was the way the women discussed in this article characterised it are lightning rods for debate in leftist activism and scholarship regarding brazil the several sources referenced here cover the range of evaluations of the mst fairly well my characterisation of the mst as hierarchical and resistant to dissent does not claim to evaluate the movement as a whole or even in rio grande do sul rather it pertains to the way the mst has been perceived by the women we interviewed to have acted towards the mmtr and towards mmtr activists in rio grande do sul the plausibility of this characterisation is well supported by wolfords largely sympathetic account of the establishment and functioning of mst settlements in southern and northeast brazil 9 lomnitz return of comrade ricardo flores magón 10 rubin and sokoloffrubin sustaining activism 11 see center for the humanities seeing not seeing manifesto the project draws on a wide range of sources for inspiration including artist stella working space literary critics nelson the art of cruelty and the argonauts and benítez rojo the repeating island anthropologists tsing the mushroom and de la cadena earth beings ethnomusicologist steingo kwaitos promise and political theorist white political theory it also grew out of six years of conversations between seminar participants and the 20 or so invited guests who have presented their work at the seminars since 2016 12 wittgenstein philosophical investigations 13 havens coming to life 1213 14 havens coming to life 24 less the case in the late 1990s and early 2000s the period about which i am writing at that time this perspective on the mst was not considered by either side in the streets versus institutions debate despite the fact that such a position might have contributed to alliances across the divide 49 green exile within exiles 445 50 at this point the women did not envision or at least did not suggest to me the possibility of multiple movements or organisations functioning in a horizontal network which might have been another way to enable the multiplicity and holding of difference they sought 51 koselleck futures past 52 in these ways the mmtr activists began to enact a political philosophy similar to that developed by the women leaders of the movement for black lives two decades later woodly radical black feminist pragmatism declarations and conflicts of interest research ethics statement the author conducted the research reported in this article in accordance with ethnographic field research standards consent for publication statement the author declares that research participants informed consent to publication of findings including photos videos and any personal or identifiable information was secured prior to publication the interviews from which the article draws most heavily took place in 2002 and 2004 in maronata andalinas and ralindo unless otherwise stated quotes in the article come from these two sets of interviews which were conducted jointly by my daughter emma sokoloffrubin and myself conflicts of interest statement the author declares no conflicts of interest with this work all efforts to sufficiently anonymise the author during peer review of this article have been made the author declares no further conflicts with this article

this article has been peerreviewed through the journals standard doubleblind peerreview process where both the reviewers and authors are anonymised during review

introduction each year in the united states millions of young adults earn postsecondary academic credentials 1 motivated by the belief that the path to career success starts in higher education 2 3 while these credentials are an important signaling device in the labor market 4 5 a successful start to young workers careers can also be influenced by factors beyond individual control an important example is the business cycle recessions increase job competition and generate fewer opportunities to begin careers on a strong footing 6 7 8 9 and increase the risk of unemployment and underemployment 10 11 12 at a time when young adults are vulnerable to labor market setbacks as they try to establish independent lives 13 compared to previous downturns in the us the great recession that officially lasted from december 2007 to june 2009 and caused approximately 8 million jobs to be lost 14 is notable for its exceptionally adverse impact on the labor market unemployment rates in the us surged more sharply during the recession and receded more slowly after it than at any other time since world war ii 15 16 17 18 the pain was felt widely among young adults for example employment among young adults born in 1982 or 1983 with only a high school diploma fell 104 percentage points between december 2007 and june 2009 to 781 12 in october 2009 when the us unemployment rate peaked at 100 unemployment among recentlygraduated bachelors degree holders aged 20 to 29 reached 176 or nearly double the rate from two years earlier 19 such statistics are informative of the weakness of the labor market as experienced at the time by young adults but less is known about how they fared over the longer term 20 even though young adults affected by the 200809 recession are still early in their careers and their lifetime earnings remain an open question this knowledge gap deserves attention because evidence shows that entering the labor market in a downturn can hinder wage growth and cumulative earnings for years or even decades 7 21 22 23 24 if early career conditions offer clues to future labor outcomes what might the conspicuously difficult conditions of the great recession suggest about the longterm economic performance of young workers who encountered the recession headon and on the timing of labor market entry how much difference might a few years have made in the way the recession shaped the early trajectory of a career a decade removed from the 200809 recession enough time has passed to allow us to begin considering these two questions in this study we analyzed two labor outcomesannual employment rates and annual wagesover a sixyear period for three cohorts of young adults graduating in the late 2000s and early 2010s stratified by sex and grouped by education attainment level cohorts were drawn from a pseudopanel generated from american community survey microdata to contextualize variability in outcomes relative to the timing of the economic downturn we staggered the timing of each cohorts recession exposure to simulate labor market entry before during and after the recession respectively variability was interpreted through the educationlabor outcome gradient which describes how higher levels of education correspond to higher annual wages and better odds of employment and is often referred to as the return to schooling 25 26 the notion of a gradient is one of the key developments in econometrics from the last halfcentury with roots in the human capital models of becker 27 and mincer 28 and the market signaling model of spence 29 more than just establishing the positive correlation between amount of schooling and wage earnings 30 it explains how the investment in time and money in higher education is rationalized by the anticipated return on that investment in the labor market 2531 with higher education having become a normative part of the transition to adulthood 32 33 examining earlycareer labor outcomes on an education gradient is doubtless relevantespecially if those outcomes respond dynamically to the timing of recession exposure some proportion of young adults will be affected by each future recession that comes to pass but how different might the effect be if it is a peripheral rather than direct encounter this study helps to fill the gap regarding how young adults labor outcomes and outcome trajectories were affected by the 200809 recession 20 given the construction of our cohorts our findings are generalizable primarily to young adults who completed their formal educations on a traditionalstudent timeframe still the study contributes a new way of considering the variability of earlycareer trajectories launched at different points relative to a major exogenous shock and offers insights into the shape and resiliency of the education gradient for a recent generation of young workers it also contributes clues to several potentially lasting changes in the proportions and behaviors of working nonworking and collegegoing young adults after 2008 on the basis of a long literature asserting the advantages of higher education in the labor market we expected no recessioninduced changes to the overall shape or ordinality of the gradient regardless of entry timing individuals with higher education credentials were better protected we further conjectured that the recession influenced outcomes in cohortspecific ways reflecting whether workers entered the market when the economy was strong weak or recovering for young adults entering in 2006 during the mid2000s economic boom we expected job displacement in all education groups and stalled wage growth after 2008 considering the severity of the 200809 recession and the weakness of the subsequent recovery we expected employment and wage growth to be especially sluggish for young workers entering in 2009 resulting in worse employment and wage outcomes and more compression within the gradient than either other cohort in any observation year for young adults entering in 2012 when unemployment among recent college graduates had begun to decline 37 we expected a middleoftheroad performance marked by entry into a stillweak labor market that was slowly returning to a normative macroeconomic state our results supported many of these expectations but not always in a cohortspecific way evidence for the gradient and its protective effect were strong as workers with higher levels of education were generally less harmed by the recession and more advantaged during the recovery but groups in the 2006 cohort did not have universally superior longitudinal outcomes despite the favorable conditions of their labor market entry nor did groups in the 2009 cohort have universally worse outcomes despite their uniquely disadvantageous start additionally recession effects at the cohort level were as often subverted by structural disparities in sex as by disparities in education attainment suggesting that the educationlabor outcome gradient was not the only phenomenon that can withstand even the deepest recessions materials and methods data the data used in this study come from the american community survey publicuse microdata series for each year between 2006 and 2017 contained in the ipumsusa database at the university of minnesota population center 38 the acs is a demographic housing and workforce survey conducted by the us census bureau on a national random sample of the us population while data from the us department of labors current population survey is often used to study labor markets use of acs data is not without precedent one consideration when comparing acs and cps on labor indicators is the fact that acs is a far larger survey approximately three million households are sampled each year by acs compared to 100000 by cps 42 the larger sample size of the acs allows for greater reliability when analyzing groups within the sample this was an important concern given that forming our analytic sample ultimately excluded 792 of observations in an original ipumsusa data set of 94 million records slight differences between acs and cps exist in the way survey universes are defined individuals in households are deemed eligible for interview employment status questions are worded and income is reported 43 44 but income estimates are highly comparable between the two surveys 43 and employment estimates have increasingly converged after 2007 44 both are nationally representative samples as well our analysis was restricted to noninstitutionalized civilians with a known birthplace aged 18 to 34 years and reporting having completed at least a high school diploma or equivalent at the time of survey these criteria excluded individuals in the armed forces and individuals who did not reside in a censusdefined household or noninstitutional group quarters also excluded were individuals who had not yet graduated from high school a small fraction of the acs sample was further excluded after restricting raceethnicity categories to the four largest groups nonhispanic white nonhispanic black hispanic and asian to maintain consistency in our definition of employed persons as wage or salary workers with nonzero earnings we excluded unpaid family workers and the selfemployed in the interest of complete records we dropped 6042 females after crosstabulation revealed missing information about their fertility status in the previous year variables our outcomes of interest were current employment and annual wage where employment and wage only applied to individuals who worked for an employer for pay we coded employment at the individual level as a dummy variable where being employed 1 mean annual employment rate was the proportion of all members in a cohort group who were employed fulltime or parttime whether they were also enrolled in college median annual wages were calculated for each cohort from the groupwise aggregation of annual wages reported individually for the previous 12 months at time of survey adjusted for inflation to midyear 2017 dollars using consumer price index multipliers from the us bureau of labor statistics 45 extremely highearning individuals were preemptively topcoded at the 995 th percentile by year by state in the ipumsusa data set 38 but to further reduce potential skewing we winsorized the right tail of the wage distribution to the 98 th percentile of incomes reported by graduate degreeholders in the full analytic sample our regressor of primary interestlevel of education attainmentwas a factor variable operationalized at four levels high school diploma or general equivalency diploma associate degree bachelors degree and graduate degree hsdged was the reference group individuals who reported completing some college but no degree were coded as high school graduates we supplemented education attainment with eight independent variables as controls of which five were dummycoded college enrollment birthplace having given birth in the previous year parttime employment and employed at a job with a siegel occupational prestige score of 406 or higher where the score represented the median value for the full analytic sample for each binary indicator individuals for whom the indicator did not apply were coded as 0 eg all males were coded as 0 for the recentbirth variable nonemployed persons were coded as 0 for parttime employment etc remaining variables were raceethnicity observation year and years of experience race ethnicity was a factor variable with four levels nonhispanic white nonhispanic black hispanic and asian observation year was a sixlevel ordinal factor variable with levels corresponding to acs survey years the survey year in which an individual was observed for the first time was coded as 1 and each subsequent year was a unit increase this coding allowed us to measure elapsed time and capture period effects although each cohort entering observation in a different survey year meant that the period effect of a given survey year was assigned to a different observation year and required crossreferencing prior to interpretation finally on the assumption that individuals entered observation with no work experience we captured the effect of cumulative work experience by cloning the observation year variable as a continuous variable and subtracting 1 from each record to start the count at 0 years of experience cohort assignment and attrition young adults are increasingly disposed to pathways that combine alternate or delay the roles of school and work and prolong their transition to adulthood 46 47 this can make it challenging to know when a young adult has ended their educational career for good andor entered the labor market in a career frame of mind and it has implications for how labor market entry and cohort membership should be defined these concerns are particularly germane in recessionary contexts because individuals may intentionally delay their entry into the labor market in order to avoid or reduce their exposure to a recession one approach to addressing the endogeneity of timing entry is to focus the analysis on cohorts solely composed of individuals selected on criteria that reasonably preclude the possibility of delayed timing this can be done by identifying cohorts in the mold of the traditional student for whom the roles of student and worker are sequential and the demarcation between schooling and labor market entry is clear 48 the term traditional may be something of a misnomer in light of how heterogeneous the transition to adulthood has become for many young adults today 49 but it reflects an progression of milestones for students taking a linear school before career path to adulthood importantly it is a progression that can be tied to age which can be used as a cohort eligibility criterion if the average age at high school completion can be assumed as 18 or 19 years a traditional postsecondary pathway would have a high school graduate matriculate within a year or two and complete an undergraduate credential approximately two years later at around age 21 or 22 or four years later at age 23 or 24 if a recentlygraduated fouryear college graduate continued on for a graduate degree at least two or three more years would pass before that student concluded their education for good and transitioned to the labor market by this logic we can create synthetic cohorts from our analytic sample to follow through time in approximately the same manner as a panel study using longitudinal data 50 51 this pseudopanel approach is a familiar method in labor economic research for working with crosssectional data we can also begin observing each cohort in a different year to expose it to the recession at a different time hence we created a prerecession cohort that entered the labor market in 2006 a recession cohort that entered in 2009 and a postrecession cohort that entered in 2012 although only a few years separate one cohorts entry from the next each entry year represents a different macroeconomic environment 2006 was the peak of the mid2000s boom 2009 was the nadir of the recession and 2012 was when the recovery began to gather strength next we sorted eligible members of our analytic sample into the three synthetic cohorts according to the birth year that matched the expected age for each education attainment level for the year when each cohort was first observed because the first year of observation for each cohort was spaced three years apart we defined expected ages as threeyear spans high school diploma or ged at ages 18 to 20 twoyear associate degree at ages 21 to 23 fouryear baccalaureate at ages 24 to 26 and graduate degree at ages 27 to 29 while narrow these expected age ranges are consistent with an ontime high school graduation at age 18 or 19 and with studies predicating that most collegegoers who finish undergraduate degrees do so by their mid20s eg 8 9 39 importantly these age rangesupon translation into birth year rangespreserved mutual exclusivity in each education level within and between cohorts which was essential for producing consistent cohortlevel estimates in our models 50 51 of the 5862332 records in the analytic sample onethird of them matched on birth year and education attainment level and were assigned to a cohort individuals assigned to a cohort were also sorted into four mutually exclusive categories of worknonwork status worker only studentworker student only and not in employment education or training sorting was based on the crosstabulation of acs variables indicating labor force participation and college enrollment status individuals reporting unemployment or no labor force participation at time of survey were coded as neet unless they also reported being enrolled in college whereupon they were coded as student only no distinction was made in the status variable between fulltime and parttime employment among individuals coded as worker only or studentworker to generate a more pragmatic count of workers and nonworkers and in the interest of sample consistency we crossreferenced our status variable with individuals wage earnings if in a given survey year an unemployed person reported wage earnings we coded that person as employed on the assumption that those earnings indicated that person was employed at some point in the previous 12 months but not specifically at the time of survey worker only and studentworker were the only categories corresponding to being employed in our employment outcome variable table 2 summarizes cohort composition by education attainment worknonwork status college enrollment status employment status and sex ratio for the first year of observation we use the first year because an essential presumption we make about our pseudopanel is that observed individuals completed the credential appropriate to their age as traditional students and thus had no work experience when we observed them for the first time in 2006 2009 or 2012 in that regard everyone in a cohort entered observation on the same footing ie as labor market novices 7 and we can argue that the first observation of employment whether in year 1 or later was their first entry into the labor market following the completion of their schooling 56 if we further assume that the attributes that selected individuals into observation were fixed we could treat each cohort as a form of stationary population for which there would be no change in size age distribution or composition from one year to the next 57 but this assumption is problematic while birth year is certainly a fixed attribute for individuals education attainment is not it is implausible that no cohort members acquired higher note expected birth year ranges assume a traditionalstudent pathway whereby college enrollment follows high school graduation without a lengthy delay and continues without interruption until the desired academic credential is achieved credentials during their six years of observation certainly the proclivity for higher education among young adults means we should expect a substantial number of high school graduates observed at market entry to earn postsecondary degrees within the next five years but any person earning a higher credential before being rightcensored becomes ineligible for further observation in their original cohort because the age at which they earned the higher degree violates the traditionalstudent assumption required to originally observe them in that cohort we must expect cohort sizes to change over time as individuals are lost to observation given the mutually exclusive birthyear structure of our pseudopanel some of the attrition in one cohort will be captured in a later cohort however because each annual crosssection of cohort members is drawn from a different population sample it is impossible to follow individuals through time and know how much attrition is being recaptured fortunately if the groupwise attrition pattern is reasonably consistent across cohorts from one observation year to the next we may assume there is no substantive change in how groups are constituted over observation time this is because in a pseudopanel the basis for group membership remains fixed at the group level making the group the unit of analysis instead of the individual 58 even if a group loses individual members to attrition remaining members still share the same birth year range and education requirements figs 1 and2 show the size of the cohort population at each level of education by survey year for females and males respectively by the end of observation the overall size of female cohorts was approximately onequarter smaller on average than their peak size in year 2 while male cohorts were about onefifth smaller most of the attrition was in the hsdged group as the cohort population declined over time so too did the proportion of high school graduates female cohorts showed more attrition than males their proportion of hsdged fell from 65 when first observed to 51 or less at end of observation regardless of cohort or sex the longitudinal hsdged attrition pattern necessarily dovetailed with growth in the proportions of young adults earning higher degrees with their larger cohort sizes females consistently outnumbered males in postsecondary degrees earned each year but the disparity in higher education attainment is especially illustrated by the consistently greater proportion of females with higher degrees compared to males in any given cohort or year because we analyzed our cohorts separately by sex these disparities did not represent an attrition problem between cohorts for the purposes of our study similarly the slight yet highly comparable increase with each later cohort in the proportions of individuals with postsecondary degrees during the first year of observation allowed us to conclude that our cohorts were appropriately consistent through time empirical strategy all statistical analyses were conducted in the r statistical programming language 59 with the aid of specific libraries identified below for greater representativeness of the us young adult population we weighted our data using personweights provided by ipumsusa 38 on the basis of distinct gender differences in the transition to adulthood and early career we analyzed labor outcomes for males and females separately we began by describing mean annual employment rates and median annual inflationadjusted wage trajectories for each cohort by education attainment level using the survey library 64 we tested groupwise differences in trajectories within and across cohorts using twoway anova and tukey multiple pairwise tests to assist in interpreting trajectories we also described the distribution of worknonwork status levels by cohort and observation year we then turned to estimating the effect of education attainment on mean employment and wage outcomes it is wellestablished that education attainment is positively correlated with both employment and wage and it is obvious that wages are earned by the employed these facts lie at the heart of a classic endogeneity problem involving selfselection employed individuals tend to earn higher wages if they have higher levels of education but it is precisely those individuals with higher levels of education who tend to be employed in the first place this selfselectivity into employment makes it likely that the education gradient of employed individuals will not be representative 66 69 70 but the cause behind such selectivity is an unobserved variable positively correlated with education attainment and onthejob performance individuals with greater ability are often predisposed to using their ability to obtain higher levels of education and earn higher wages regardless of their education level 2671 this situation gives rise to our endogeneity problem in a classicallystructured ordinary least squares model regressing wage on education education is the predictor variable while abilitybeing unobservedis an omitted variable whose effect on wage is captured in the error term 72 if in a sample of workers those with greater ability have higher levels of education and higher wages the estimated values for the predictor and error terms will both be larger in other words the predictor variable will be positively correlated with the error term which will bias the estimator upward 26 73 74 we will assign more influence to education attainment than it actually has this is a problem because we wish to estimate what the unconditional mean wage would be based on education attainment data from all individuals in our sampleincluding those individuals who did not worknot the mean wage directly conditioned on being employed and indirectly conditioned on education attainment to reduce this bias in the marginal effect on wage for different levels of education we implemented a twostage heckmantype sample selection model specifically we used the sampleselection library 70 to generate a tobit2 model for jointly estimating a selection equation for the individual likelihood of being employed and a outcome equation for mean annual log wage the selection equation is a probit model that predicts the likelihood of selection for each cohort member and identifies in the form of the inverse mills ratio their individual selection hazard these imrs are used as the omitted regressor in the outcome equationone that informs the equation on the estimated likelihood of each person in a sample to be employed 74 75 76 in accordance with standard practice for ensuring the selection equation is adequately identified we employed exclusion restrictions ie variables that correlate with selfselection into the noncensored group providing the data on the outcome of interest but not with the outcome itself 7075 we chose four regressors to predict selection into employment yet not directly influence wages having recently given birth place of birth college enrollment status and observation year a recent birth is more likely to influence whether a person opts to temporarily withdraw from the labor force than their wage rate if they stayed employed 77 78 birthplace may be a more appropriate predictor of employment than wage given that a substantial share of us immigration is employmentbased 79 and wage discrimination based on national origin is unlawful 80 college enrollment status may instrument for selectivity into employment since employment can compete with school for a persons time and attention 81 82 indeed many fulltime students do not work while attending school 83 we might also expect a joint effect from birthplace and college enrollment given the propensity for many foreignborn young adults to study at us postsecondary institutions 84 an interaction term will allow us to capture it lastly if we theorize that unemployment is a product of the macroeconomic climate observation year can be a proxy for the economic conditions of each survey year the exclusion restriction extends to the outcome equation as wellonly inverted since we want instruments that correlate with wage but not with likelihood of employment we chose four variables for exclusion parttime employment occupational prestige years of experience and raceethnicity the merits of the first three variables are selfevident although our measure of work experience assumes a traditionalstudent pathway for every observed individual meanwhile we assigned raceethnicity as a regressor in the outcome equation on the basis of its established and persistent negative correlation with wage broadly speaking the recession coincided with a decline in c1 female employment in year 4 that continued until the end of observation all groups were affected to varying extents high school graduates experienced a drop of almost 5 percentage points between 2008 and 2009 the steepest loss among groups but it was bachelors degreeholders who showed the greatest longitudinal decline from 92 employment in 2006 to 855 employment in 2011 their groupwise mean rate was falling two years before the recession occurred the recessions immediate effect can be seen as well in the lower mean employment rate of c2 females entering the labor market in 2009 compared to c1 entrants in 2006 employment did not change substantially over the observation period except for bachelors degreeholders who again showed steady annual rate declines and the largest cumulative drop between 2009 and 2014 from the same starting employment rate above 90 in 2009 bachelors and graduate degree trajectories diverged after the latter group stabilized in 2011 at around 88 results descriptive results mean annual employment rates employment rates among c3 groups were perhaps the most varied significant employment weakness in 2012 among hsdged and associate degreeholders was rapidly overcome in subsequent years making them two of only three groups among female cohorts to end observation with a higher mean employment rate than they started with graduate degree employment followed the shallow longitudinal decline of their peers in c2 while bachelors degree employment fell in similar fashion finally bucking the pattern of the previous two cohorts relative to 2006 the fall in initial employment rates for hsdged and associate degreeholders in 2009 and 2012 is conspicuous student only group was 62 larger than the c1 equivalent a similar picture emerges with the proportion of neet in each cohort although the amount of yearly change was smaller and the recession effect was modest relative to the longitudinal growth trend in this group although c2 and c3 showed slightly larger initial proportions of neet compared to c1 by year 6 all three cohorts had similar proportions of neet we note an interesting recessionlinked relationship between the growth rates of worker only and neet groups that resulted in each cohort with about the same neet proportion at end of observation in c1 the overall growth rate among neets was substantially greater than among workers onlynot an unexpected outcome given the late timing of the recession for individuals entering in 2006 by contrast the same two groups in c2 grew at about the same overall rate while c3 neets grew at a slower rate than workers only males male employment trajectories and cohort distributions are shown in fig 4 in many ways males experienced the recession as females did but several differences stand out for example in 2008 employment decline among c1 males only occurred among individuals with high school diplomaged or associate degree as their highest credential and while both groups lost 3 to 4 ppts in average annual employment rate by 2010 both returned to growth in 2011 the steady decline in employment rate seen for almost all female groups was reversed for all male groups except the two c1 groups just described as was the case with female cohorts cumulative growth was strongest for associate degrees and high school graduates in c2 and c3 males with bachelors degrees were consistently employed at nearly the same rate as males with graduate degrees in another echo of female trends however males in the lower half of the education gradient experienced more growth than their female peers and male groups with the highest degrees often showed incremental growth instead of incremental decline the female pattern of sharply lower employment at labor market entry for high school graduates entering during or after the recession was also seen for males and for the same reasons young adults delaying their entry into a weak labor market by enrolling in college or young workers unable to find jobs and being idled at home somewhat surprisingly given the lower likelihood of males to earn academic credentials student only males in c2 and c3 comprised nearly the same proportions of their cohorts as their student only female counterparts in the first two years of observation equally interesting is the recessioninduced trend among c1 neet males in 2007 and 2008 they represented no more than 58 of the c1 cohort before climbing approximately 25 ppts by 2011 to 84 where the proportion would remain plus or minus a percentage point for the remainder of their observation period and for the entirety of c2 and c3 this is perhaps the most prominent evidence so far for a longterm recession effect that affected males more negatively than females regardless of cohort males with bachelors or graduate degrees experienced the least amount of employment volatility of any group or sex at least relative to the highwater marks set by c1 individuals during their first two or three years of observation before the recession c1 males at the two highest levels of education entered in 2006 at about 9495 employment and largely remained there throughout observation but even among males in the upper half of the education gradient those with graduate degrees managed to build distance from those with bachelors degrees whereas the recession caused employment in the latter group in c1 to stall and decline the former group held fast at about 96 employment for four straight years and in 2010 graduate degreeholders in c2 avoided the minor bump in joblessness that befell bachelors degreeholders resulting in a 23 ppt employment rate deficit that persisted in c2 for the next four years and was observed in all six years of c3 descriptive results median annual wages we show young workers wage trajectories in in contrast with the sexdependent divergence in employment trajectories median annual wages grew over time for both males and females and fell along the same education attainment gradient with higher credentials earning higher wages with relatively few exceptions wage growth occurred annually for ft and pt workers alike direct recession effects were largely absent wages grew from 2008 to 2010 for c1 workers in the third and fourth years of their careers and rather surprisingly almost all c2 ft workers entered observation in 2009 with higher median wages than their c1 peers in 2006 regardless of cohort or sex median ft wages for bachelors degrees or higher were only a few thousand dollars greater than the pooled median for ft and pt workers not shown this is attributable to the much smaller median wages for pt workers across education levelsoften only onequarter to onethird of ft amountsand the large ratio of fulltime workers to parttime workers the recession had minimal impact on this despite the numerous ways wage trajectories were similar for males and females they also differed by sex in three interrelated areas first female ft workers showed significant wage compression compared to males from lowest to highest level of education female median annual wages varied by only about 40000 in any given year while male wages varied by up to 55000 constrained by a narrower wage range female workers experienced smaller wage premiums for each higher level of education as an example male graduate degrees earned an average of 14500 more in ft median wage per year than male bachelors degrees which themselves earned up to 17415 more than male associate degrees on average for females with the same credentials the dollar amount of each ft premium was up to onethird smaller second ft median annual wages at initial labor market entry were consistently higher for males regardless of group for all groups except graduate degreeholders ft female workers pooled across cohorts showed a gender wage gap equal to about 123 of the ft female median wage the gap was 167 at the graduate degree level among pt workers most groupwise gaps were nonexistent or nearly so however this wage parity is overshadowed by the fact that female workers were more likely than male workers to be working pt not shown among young adults who were in the worker only category the male ptft ratio was as much as 74 smaller than the female ptft ratio in a given observation year third males tended to show greater median annual wage growth than females this is particularly evident when contrasting the median wages of ft males and ft females in the two highest education groups median annual c1 wages for females with bachelors degrees averaged 45 growth relative to the previous year compared to 67 for equivalent males for c2 workers with bachelors degrees the recession cut the annual growth rate for females by half but only by onethird for males a similar pattern of male advantage was observed among workers with graduate degrees the general consequence of these various gendered differences was a growing disparity in median wage earnings from the very start of observation sometimes resulting in shockingly large wage gaps a male with a bachelors degree entering the labor market in 2006 for example earned a median wage of 39696 compared to 36087 for a female with a bachelors degree in 2011 the same male worker earned 54175 while the same female worker earned 44424 a male with a graduate degree started in 2006 with a median wage premium of about 18044 relative to a male with a bachelors degree by 2011 the premium had grown 46 to 23837 for females in the same context the premium grew only 15 from 13232 to 15169 similar widening gaps were seen in other education attainment groups and across cohorts indicating a universal pattern it is important to bear in mind that these wage disparities may have been influenced by uncaptured or unobserved conditions nonetheless they clearly suggest that the educationlabor outcome gradient was not genderequal for young adults before during or after the recession selection model results tables 3456show results for the two stages of the heckit model by cohort stratified by sex coefficients from the firststage probit equation estimate the latent individual likelihood of being employed in a given year and are presented for males and females in tables 3 and4 respectively coefficients from the ols multiple regression equation estimate the size of the mean annual log wage and are shown for males and females in tables 5 and6 respectively we begin however with a review of model fit below we use the term significant to refer solely to statistical significance at the 95 confidence level and substantial to describe effect size model fit goodnessoffit statistics at the bottom of show that selection bias was present in the model data the inverse mills ratio which is given by sigma � rho where sigma is the standard error of the residuals in the probit equation and rho estimates the correlation between the residuals of the probit and ols equations was highly significant imr was also negative informing us that correcting for censored individuals reduced the mean size of the annual wage this is consistent with the notion of the reservation wagethe lowest wage a person will accept for a particular joband its role in a persons decision to work during a recession we can think of censored individuals in our data as potential workers whose reservation wages had not been met and thus chose not to enter the labor force this does not of course mean that every censored young adult in our data preferred not to work during periods of mass job loss and weak hiring the decision not to work is often made reluctantly we might instead think of the rapid loss of jobs after 2008 as equivalent to the rapid production of jobs whose wage rate is 0 and the increase in voluntary joblessness as the expected outcome when workers are unwilling or unable to lower their reservation wage to 0 absent a recession many of these censored individuals would have found jobs that met or exceeded their reservation wage thus making themselves observable to us the negativelysigned imrs indicate that the contribution of those workers wages would have pulled the overall mean wage higher in table 5 we can see that the proportion of nonworkers by cohort rose sharply after 2008the c1 male cohort had fewer censored individuals than the c2 or c3 cohorts both of which were 179 censored the proportion of employed males fell after recession onset and we may infer that this was partly because displaced workers could not find replacement jobs that met their reservation wage note that while females also experienced a recessiontimed increase in unemployment it was a smaller climb from a higher setpoint c1 females were 162 censored compared to c2 and c3 females censored at 197 and 198 respectively female workers appear to have been slightly more likely than males to remain out of the labor force andor find jobs that met their reservation wage two other goodnessoffit measures shown in tables 56 apply specifically to the ols equation multiple r 2 ranged from 0526 to 0571 indicating that over half of the variance in the log wages in each cohort was explained by the biascorrected ols model similarly the root mean square error of residuals for each cohort ranged between 082 to 0845 indicating mean variance of less than 1 log unit all these measures were smaller than their equivalents generated by uncorrected ols regression not shown indicating that the heckit model was a better fit to the data probit results for selection into employment probit equation coefficients represent the values that maximize the likelihood function for producing the imrs used to correct for selection bias in the outcome equation since these imrs represent a latent variable there is no direct interpretation for the coefficients that produced them we can however evaluate them more generally in terms of whether they were abstractly associated with a greater or lesser likelihood that an individual would be employed certain probit terms had consistently negative effects across cohorts and were representative of conditions little changed by the 200809 recession for males these were birthplace current enrollment in college and the interaction between the two effects for females these were birthplace current enrollment in college and having given birth in the previous year the negative effects on employment likelihood for male college students born outside the us while significant and substantial would not be unexpected if many of those students were admitted to the us on f1 student visas that largely disallow offcampus employment 87 a condition that would be entirely exogenous to recession conditions for females however college enrollment had a substantively lesser negative impact on employment likelihood than having given birth or being born outside the us by contrast level of education was a consistently positive effect at the cohort level for males and females each higher level of education was associated with a significantly and substantially greater likelihood of selecting into employment the strength of this effect was generally larger for males than females and smaller for c1 than c2 or c3 unlike with most other variables there was heterogeneity across cohorts in the period effect as shown by coefficients for observation year this effect revealed a recessioninduced drag on employment that lasted several years and affected females more than males negative coefficients for c1 in the latter half of observation reflected labor market weakness after 2008 as the only significant negative coefficients to appear in our probit results they affirm the descriptive evidence in figs 3a and 4a that timing of labor market entry had a distinct effect on employment relative to 2006 individuals in c1 were less likely to be employed in a recession or postrecession year but for young adults in c2 entering at the bottom of the recession meant that subsequent years effects were relative to this nadirthere was nowhere to go but up even if that climb was slow or delayed males in this cohort did not experience a substantive positive period effect on employment until year 4 while females did not experience any before being rightcensored this is consistent with the elevated weakness in hiring that characterized the first few years of the economic recovery 88 89 by contrast individuals in c3 showed period effects that were larger and grew more rapidly over time representing the kind of steady yearoveryear improvement seen in a strengthening economy ols results for mean annual log wage in a heckit model we interpret the coefficients from the outcome equation as we would for any ordinary ols regression model and because of the corrective effect of the imrderived regressor they will be less biased than the coefficients generated from ordinary ols models table 5 presents the coefficients and standard errors for male cohorts and table 6 contains the same for female cohorts most of these coefficients may be directly interpreted as percent changes to the intercept value when a binary variable is equal to 1 or in the case of continuous variables for each additional year of experience 26 note that this guideline does not hold well for coefficients more extreme than about 02 and that these larger effects are discussed below after the appropriate loglinear transformation as seen earlier in the probit equation regressor coefficients in the wage equation tended to be consistent in size sign and significance across cohorts compared to nonhispanic white males and all else equal asian and hispanic males mean log wages were 41 to 79 higher depending on cohort while black males log wages were approximately 14 to 15 lower female cohorts showed a similar pattern although the penalty for black females was substantially lower working parttime was especially unfavorable a coefficient of 102 or 103 translates into earning 64 less than the reference group regardless of cohort or sex working a job with an occupational prestige score in the upper half of the distribution increased the log wage by up to onefifth for female workers and around onequarter for male workers these estimated effects did not much vary with recession timing work experience on the other hand was strongly heterogeneous with c1 males and females experiencing distinct recessionbased patterns not found among their c2 or c3 peers in table 5 we find that the mean c1 male log wage grew by 20 with each additional year of experience holding all else constant however as these workers traversed the second half of their observation period the wage premium for additional years of experience was increasingly offset by the period effect conveyed in the yearssquared term in year 3 the coefficient of the linear effect for having accumulated two years of experience was offset 132 by the nonlinear effect bringing the adjusted coefficient to 0316 this equates to a 2008 mean wage that was 372 larger than the 2006 mean wage after the log conversion in year 4 the coefficient for having three years of experience was offset 197 by the nonlinear effect to 0438 equivalent to net growth of 55 of the 2006 wage after the log conversion in 2010 after four years of experience the net gain to the annual wage was equal to 709 of the 2006 wage in 2011 it was equal to 84 these male work experience coefficients are readily interpreted as recession effects males who entered the labor market in 2006 had a few years to accumulate work experience in a strong economy before the recession occurred with each additional year earning a high wage premium the size of the linear effect was substantively smaller for c2 and c3 males but nonetheless continued to be positive and significant what did not persist for c2 and c3 males was the penalty for accumulated experience which can be attributed to the recessions trough occurring either at the moment of labor market entry or three years prior when we began observing these groups of workers the worst of the recession had already passed if only barely both cohorts were thus moving away from the recession instead of toward it by comparison work experience effects for female cohorts resembled those for males but in a muted fashion that showed limited heterogeneity at the cohort level female cohorts mean log wages gained more with each additional year of work relative to male cohorts and the disparity between female c1 and c2c3 linear effects was narrower and while the negative nonlinear effect on c2 and c3 mean wages did not disappear for females it was greatly reduced relative to c1 interpretation of the endogenous education attainment variable the final ols equation variable to discusseducation attainmentalso appears in the probit equation making it the lone endogenous regressor in our heckit model as a result this variables effect on log wage must be adjusted to account for the fact that its effect on selecting into a wageearning state had previously been estimated 90 91 show the marginal effects for highest education level after being adjusted downward using the approach by sigelman zeng 91 even after correction it is clear that education was a major wage determinant across cohorts and survey years corrected effects show that female workers experienced relatively greater returns to schooling than male workers relative to an hsdged female workers with bachelors degrees enjoyed a wage premium equal to 140150 of the hsdged groups mean wage compared to only 114123 for males with bachelors degrees while a graduate degree raised male workers mean log wage to 177187 of the value of an hsdged females mean log wage grew more than 230 for the same credential this was a universal outcome for both sexes regardless of recession effects discussion in this study we examined how the timing of the great recession affected young adults entering the labor force and accumulating work experience in the years before during andor after the recession we gave particular attention to analyzing labor outcomes on an education gradient to see what kind of recession protection was afforded to individuals who invested in higher education could we identify differences in longitudinal trends based on when cohorts interacted with the recession or the recovery would those differences vary across the education gradientand if they did what would that signify we generally expected to see two patterns labor market outcomes would favor workers with higher degrees regardless of when one entered the market or encountered the recession and recession effects would be seen across the entire gradient but in ways that reflected each cohorts unique exposure to the recession our findings confirmed the first pattern but only partially substantiated the second pattern signifying that even the most severe economic downturn in generations could not repeal the structural nature of young adults early career outcomes despite appearing capable of imposing its own longterm effects we illustrate this point below in three takeaways takeaway 1 the recessions most important effects on employment were lasting ones the 200809 recession had immediate effects on the two cohorts that directly encountered the recession most prerecession groups lost momentum in the recession resulting in lower employment rates at year 6 than their peers in later cohorts and all recession groups had lower employment at the start of observation than their peers in c1 these findings corroborate previous evidence that young workers were heavily displaced by the recession and should not be discounted but the recessions larger legacy on employment may rest with how certain groups trajectories appeared permanently altered after 2008 this beforeafter effect is seen in the steeper decline in employment rates for all c1 female groups during the latter half of observation relative to later cohorts and in the flat employment trajectories of c1 males with less than a bachelors degree relative to later cohorts it might also be shown by the fact that almost no c1 group male or female was able to recover enough momentum by 2011 to attain the employment rates of c2 or c3 at the end of observation although this may not be a fair comparison given that c1 was unique in experiencing the recession toward the end of their observation period more worrisome might be the recessions lasting effect on the employment of young adults with bachelors degrees c1 female employment in this group fell faster after 2008 than for c1 females with associate or graduate degrees females with bachelors degrees were the only group in c2 to show decline during observation which strikes us as curious considering that they entered the labor market in its weakest state for males with bachelors degrees the recession marked the start of a widening employment gap with graduate degreeholders that began in c1 but continued across c2 and c3 these findings of employment weakness potentially argue for a small yet meaningful devaluation of fouryear degrees in the recession and postrecession labor markets while far from conclusive they are of a piece with the larger education coefficients seen in the probit selection equations for c2 and c3 relative to c1 that suggest a persistently greater tendency after 2008 for young adults with more than a high school diploma to choose employment on lesser terms than they might prefer 94 takeaway 2 labor outcomes were influenced less by the recession than by education attainment or sex lasting or not it must be acknowledged that the 200809 recessions effects on employment and wages paled in comparison to the distinct and sometimes large disparities in outcomes by education or sex young adults with high school diplomas or geds were consistently the least employed and lowest earning groups by a wide margin and the recession produced no meaningful change to that relationship nor did the recession greatly disturb the high employment or wages of graduate degreeholders or modify the shape of the education gradient across cohorts between 2006 and 2012 young adults with a given level of education entered observation at about the same starting median wage and left observation five years later with roughly the same higher median wage such consistency over time was paralleled by the nearly unwavering dispersion in median wages across levels of the education gradient which was far greater than any difference in wages for a given education level between two cohorts equally consistent were the weaker outcomes for females relative to males at a given level of education on almost every employment or wage metric even the closure of the gender wage gap for pt workers is diminished by pt workers much smaller mean annual wages and female overrepresentation the structural nature of education level and sex in shaping labor outcomes has been long established and our findings illustrate how little the recession appears to have changed this at the broad level of our analysis the sexspecific educationlabor outcome gradients that existed before 2008 continued through the recession intact this may seem perplexing and frustrating from a gender equity perspective particularly since females in our analytic sample earned postsecondary credentials at higher rates and in greater numbers than males the dearth of contextual variables in our data means we cannot prove or disprove that female workers were systematically disadvantaged before during or after the recession but our results are consistent with the literature and with other sexspecific discrepancies in our data including the contrary motion of employment rates over time for male and female graduate degreeholders and the unique susceptibility of female workers with bachelors degrees to exit employment these discrepancies clearly warrant further investigation takeaway 3 the recession may have precipitated changes that point to the emergence of a new normal in the labor market several discontinuities in the data at the cohort level show that the recession wrought small yet persistent changes after 2008 offering clues about how young adults adapted to a postrecession labor market because many of these discontinuities were subtle their repercussions may not become readily visible for years but in the aggregate they suggest that the recession marked the beginning of a new normal for young adults entering the market for example the diminishing wage return on years of experience for c2 and c3 workers and on job prestige for c2 and c3 females may be indicative of employers broadly exploiting recessionary conditions to permanently increase their wage setting ability 99 if validated this could have implications for workers longterm earning power and household wealth the sharp rise in the proportion of neet among c1 males appeared to reset the default neet proportion for c2 and c3 males as well suggesting that the recession had evolved the economy in ways that systematically removed even more young males from employment or postsecondary schooling while it is not possible from our data to know which males were affected or whether they became neet intentionally the persistence of a newly higher proportion of male neet suggests a structural shift perhaps the most significant example of a recessioninduced structural shift however is in the growth pattern in the proportion of college students who did not work the large gain in the student only proportion at first observation between 2006 and 2009 was followed by another in 2012 the rise in the student only proportion in 2009 is consistent with the warehousing of young adults in college during the 200809 recession 20100 and explains the sudden drop in the proportion of high school graduates in employment after 2008 but the further climb in the student only proportion in 2012 when the economic recovery was gathering pace speaks to something else since the total proportion of collegegoers remained relatively consistent across cohorts it is unclear if the greater proportion of student only represents a benign or worrying change for example it may characterize a greater interest among high school graduates from the classes of 2011 and 2012 to focus on college before turning their attention to a highly competitive labor market this could be benign if higher educationalready wellestablished as a priority for many young adults in the us 101 was simply prioritized by an even larger number of high school graduates on the other hand it could indicate a mounting financial burden if some of these students borrowed more to pay for college than they would have liked because of meager postrecession job opportunities for workers with only an hsdged if the return on investment for bachelors degrees is faltering it would raise the stakes for student borrowers limitations and next steps we recognize that our findings and takeaways are based on aggregate data and should be interpreted with care our creation of a pseudopanel data set and use of the heckit model were intended to improve the longitudinal analysis of crosssectional data and reduce confounding from latent selection bias but this approach has limitations for example we caution against interpreting the results of trajectories of hsdged workers in the same way as highereducated groups this is because around onefifth of each male cohort and onequarter of each female cohort was lost to attrition during the observation period and most of that attrition was among high school graduates earning postsecondary degrees thus labor outcomes for hsdged groups in year 6 were more representative of the typical high school graduate with no intentions for college than they were in years 13 as the composition of hsdged groups in years 13 necessarily included individuals who later earned postsecondary credentials and would leave our cohort while under observation collegegoing high school graduates may have helped lower the hsdged employment rate or drag down the median annual wage this could confound the reliability of estimated outcomes given the majority share of each cohort made up by the hsdged group beyond this our longitudinal conclusions are limited in the usual ways for crosssectional data developing our findings using contextrich panel data would be a natural next step that also opens the door to the causal analysis of patterns and associations revealed in this study other important directions include accounting for the wide variability implied by conditions such as employment or education and addressing the endogeneity of labor market timing regarding the former the lack of a large deviation in outcomes across cohorts at the high end of the education gradient implies a protective education effect but offers no insights into important aspects of labor including job quality and underemployment that could have broadly changed after recession onset but were not measured in our data on the latter our cohort design limits generalizability to young adults on a traditionalstudent trajectory which means our findings cannot necessarily speak to individuals who deviated substantially from this trajectory it will be valuable to analyze in future studies what proportion of young adults delayed their graduation from college to avoid a direct encounter with the recession and what their outcomes were as a result limitations notwithstanding as a first look at the labor outcomes and trajectories of young workers around the time of the 200809 recession this study offers new evidence for the differentiation of earlycareer trajectories by recession proximity and lays out several promising research directions timing mattered but so did educational attainment and much else too and it remains to be seen what the true legacy of the great recession will be for young adults who started their careers in the recessions wake all relevant data are within the manuscript supporting information files and at figshare poned1829488r17835945

the goal of this study was to analyze differences in the employment and wage trajectories of collegeeducated young workers in the united states as distinguished by the timing of their entry into the labor market relative to the onset of the 200809 recessionusing annual american community survey microdata we analyzed the first six years of employment and wage outcomes for cohorts of young workers on traditionalstudent pathways entering the market 1 in 2006 shortly before recession onset 2 in 2009 during the recession and 3 in 2012 three years after the recession officially ended we found evidence for negative effects on outcomes and outcome trajectories differentiated by the recessions proximity to workers labor market entry including lower wages for the cohort entering in 2009 however recession effects tended to be smaller for workers at the high end of the education gradient or with no direct exposure to the recession and were outweighed by gendered labor outcome disparities we also observed a possibly enduring recessioninduced rise in the number of idle young males and the proportion of male and female high school graduates enrolled in college and not workingcohort differences in labor outcomes show that the disadvantages of entering the labor market during an economic downturn appear lasting however the subordinate role of timing effects in sorting young workers employment and wage rates when compared to the stark stratification of employment and wage outcomes by education or sex is a useful reminder that these latter social structures remain key determinants of labor outcomes

parenting children with disabilities can embed intense and chronic caregiving responsibilities the experience can be both a stressful and a rewarding dimension of parenthood a number of factors influence the experiences of fathers which can create a complex parenthood process depending on the disability of the child as well as the availability of effective and efficient resources at the community level however being a recent immigrant and falling into the category of racialized minority can further complicate the fathers experiences research on the barriers faced by immigrant parents in terms of socioeconomic conditions acculturation and ability to access social programs and services for their child remains scarce in the canadian context even more limited is information available on immigrant fathers raising children with disabilities who often face unique stressors based on traditional gender roles and household responsibilities this narrative review explores the experiences of immigrant fathers raising children with developmental disabilities developmental disabilities cover a range of disabilities which include intellectual disabilities autism downs syndrome fragile x syndrome and other developmental delays children with dds may have impairments and limitations affecting their physicalbodily function their ability to perform daily activities and their participation in routine behaviours such as going to school in 2006 statistics canada reported roughly 37 of children under the age of 15 having one or more dds however in canada the percentage of children with disabilities growing up within immigrant families is not known additional help in the form of social support is necessary for parents raising children with dds however 74 of parents of the 37 of children with disabilities living in canada reported that extra help was too expensive for them and many stated difficulty in finding and accessing appropriate resources for example almost 40 of those parents reported not knowing where to go to find help the situation for immigrant mothers and fathers of children with dds is further complicated as informal and formal social support systems are often diminished following migration in 2011 206 of the total population in canada was comprised of foreignborn individuals making the country the highest population of immigrants among all g8 nations one in every five people in canada is foreign born and the numbers are rising yearly for immigrant men specifically unique challenges present themselves within the canadian context for example 75 of recent immigrant men are not able to converse in english and 36 of immigrant men work parttime not in fulltime jobs these socioeconomic factors may additionally cause further complexity for fathers raising children with dds theoretical approach parenting children with dds involves persistent and longterm challenges with associated emotional impacts such as stress for fathers and mothers who have limited social support social support is important in order to alleviate stress anxiety and frustration we apply houses conceptualization of social support which entails four dimensions of social support structural instrumental emotional and perceptive as per house instrumental support relates to financial help for families as well as the availability of other forms of tangiblecare giving services and programs structural support in the context of this review paper relates to the ease with which parents can access utilize and gain information about their childs dd emotional and perceptive forms of support are more at the personal level in houses model with emotional support focusing on the social networks present to help reduce caregiving demands and perceptive support referring to the adequacy and helpfulness of support the individual feels they are receiving this paper adopts an intersectional approach to account for the multiple and complex processes which affect particular segments of the population such as immigrant fathers of children with dds in canada an intersectional lens allows for a simultaneous analysis of social difference and identity which may link to bforms of systemic oppression…in ways that are complex and interdependent it is also a perspective that interrogates the power relations from which health disparities emerge jennings et al argue that in order to consider immigrant families of children with dds in contexts such as canada it is important to understand immigrants bcomplex social locations which are a result of various intertwined influences they highlight the need to analyze such complexity beyond the sole description of social determinants of health and through incorporating a more comprehensive analysis examining the bpower dynamics shaping immigrants experiences and disparities the objective of this review is to examine these very issues the specific question the narrative review addresses is bwhat does the literature tell us about the stressors impacting immigrant fathers of children with developmental disabilities particularly in regards to social cultural and economic barriersm ethods a narrative review is a comprehensive narrative synthesis of previously published information by following green johnson and adams method and as described below we applied a stepbystep procedure which includes identifying the sources of information used the search terms as well as the inclusion and exclusion criteria applied to narrow down the search sources of information four electronic databases were used when completing this narrative reviewpsychinfo pubmed cinahl and sociological abstracts all references found within these sources were organized and categorized using the online research management toolrefworks the specific search within each of the four main databases was delimited through the inclusion and exclusion criteria search terms and delimiting first key search terms were used within each of the four data sources the terms bfather and bdevelopmental disabilities were used across all databases yielding 822 total search results originally the term bimmigrants had been added in order to limit results specific to immigrant fathers however this yielded very few results and therefore this term was removed this further shows the limited literature in the area of immigrant fathers of children with dds therefore the term bimmigrants was removed and the larger result of 822 articles across all four databases was delimited using the inclusionexclusion criteria outlined below also initially the term bcanada was used to narrow the search in order to yield results within the canadian context however adding this term greatly reduced the number of articles as well therefore the term bcanada was removed which then yielded for a greater number of results this further illustrates the limited research conducted on immigrant fathers within the canadian context next titles of each result were scanned within each database according to the inclusion exclusion criteria for the review lastly paper abstracts were reviewed as a final step to ensure the included papers met the criteria set since we did not specify canada as a key word most of the literature reviewed was from the united states and united kingdom the years specified for the search were 1990 to 2015 key words and final search results are shown in fig 1 selection criteria the inclusion criteria included literature studying the experiences of fathers the experiences of immigrant fathers socioeconomic barriers of immigrant populations and dds in children the selection criteria excluded literature that was not focused on fathers literature that focused on disabilities caused by accidents research exploring the experiences of fathers of adults as opposed to children and nonenglish papers results using the inclusionexclusion criteria a total of 39 articles were found to be relevant across all four databases the majority of articles were published outside of canada however they form part of the review to examine the various factors involved in fathering children with dds findings have been applied within the canadian context as there is a lack of literature in this area the above search was complemented by additional search strategies we used published references recommended by our peer scholar networks as well as peerreviewed journal articles located through google scholar key phrases used for this complimentary google scholar search were bimmigrant economic barriers canada bimmigrant employment canada and bimmigrant labor force canada through this step a total of 20 additional academic journal articles were included themes the first part of the findings presents the challenges fathers face in general while parenting and caring for their children with dds along with these general challenges immigrant fathers experience additional barriers that we present in the second section due to their immigration status in canada raising children with developmental disabilities fathers of children with disabilities experience differing levels of stress as they care for their family which is strongly linked with gender parents of children with disabilities living in canada reported that their daily stress level varied from ba bit to bextremely stressful added pressure on parents to balance personal and work life resulted in over 60 of parents reporting bsometimes to balwaysf eeling under stress this strain affects all aspects of family life including parental marital satisfaction parental physical and emotional health as well as the ability to perform care giving tasks and responsibilities the stressors that most commonly affect fathers of children with disabilities are both informational stress as well as practical stressors informational stress refers to the ongoing quest by fathers for medical information in order to better understand the disabilities of their child in one study it was found that not only do some fathers feel responsible for seeking information but they also have pressure to balance family work and routine daily tasksleading to practical stress some fathers have also expressed concern in regards to health care professionals viewing them as intrusive assertive and less competent than their wives one reason given for the bias felt by men is the domination of women in the care giving field many fathers feel health care professionals are not supportive and depict fathers in a negative light this causes further frustration and stress fathers live more in the public domain in which employment is a strong priorityto fulfill the bbreadwinner role in one study it was found that some fathers show to be a strong power in the household and a main authority in the familyin terms of financial support for the child in care taking on this role forces them to repress emotions in order to be strong for the family and provide additional support for their wives huang chen and tsai also found that some fathers tend to suppress the difficulties of adjusting to the new role as a father of a child with disabilities as well as the difficulty of balancing work and family lifein order to be strong for the whole family a fear of loss of employment and financial support creates worry and guilt for fathers related to the childs medical care and treatment since most men in the household see their occupational role as primary there is increased job stress in order to further support medical expenses there are also structural limitations felt by fathers who want to be more involved in the life of their child with disabilities fathers feel a restriction by their employers who are less flexible with their work schedule and give fewer accommodations in taking time off from work compared with mothers this leads to the stress of balancing family and work life and at the same time fearing a threat of job loss marital stress is experienced by both mothers and fathers of children with disabilities according to some researchers the lack of intimacy time and communication causes increased frustration between the spouseswho begin to view their relationship as a business as wives want to spend more time with their spouse husbands tend to spend time away from home in order to strengthen their relationship however and conversely having children with dds can also lead couples to be more interdependent on each other as they take turns in caregiving and providing temporary respite to each other the stigma felt by fathers in regards to their childrens disabilities and the negative perception from outsiders are among the stressors that fathers endure the specific characteristics of the childs dd as well as worry for hisher future are also causes for great tension these stressors are reported by some researchers to be tied to decreased life satisfaction for fathers also among some fathers increased depression due to the disabilities of the child may lead them to distance themselves or become stoic towards the child as a way of coping this social isolation can harbor feelings of shame sadness anger and disappointment the father can feel overwhelmed with a loss of control in his life leading to poor physical health avoidance and isolation have been linked with lower levels of wellbeing over time in contrast fathers who display emotional stability and agreeableness have decreased parenting stress there also is limited professional help offered for fathers living with a child with disabilities and many fathers request more details of the dd this lack of knowledge leads to feelings of discomfort and can further cause a stressful environment table 1 summarizes these findings as well as the number of relevant articles found within each thematic area immigrant fathers a bdouble burden along with facing the stressors highlighted above immigrant fathers experience additional stressors which can affect the way they deal with the dd of their child we present below literature review findings on the contextual experiences of immigrant fathers who we argue carry a bdouble burden in addition to parenting and caring for their children with dds immigrant fathers experience unique stressors and barriers due to their immigrant status socioeconomic barriers there are structural socioeconomic constraints that immigrants in canada navigate on an everyday basis approximately 78 of immigrants arriving to canada within the last ten years are identified as a visible minorityindividuals who are nonwhite in colour or who are noncaucasian in race being both a new immigrant and part of a visible minority group limits individuals and their families in terms of employment and income in canada 1 of recent immigrants live below the poverty line this population has three times more probability to live in poverty than people born within the country in addition over a period of a decade after their arrival the poverty rates remains high for this population the rates are two times as high as nonimmigrants the literature points towards two socioeconomic characteristics of children with dds in canada they are bmore likely to live in poverty than children without any disability and they are bmore often being raised in singleparent families particularly by single mothers the effects of living in families with lower income on young children include negative outcomes such as decreased educational attainment and increased behavioral problems these effects can be seen to carry on into adulthood with children from low income families earning less as adults themselves immigrant fathers of children with disabilities have increased stress through financial barriers and social isolation goldring and landolt argue that the blabor market incorporation of immigrants is important for social inclusion because it determines employment income and shapes material wellbeing however immigrants insertion into the labor market is one of the most bhardest tasks scholars have highlighted the difficulties immigrants encounter in their job search as well as the lower earnings they receive compared to the nonimmigrant population precarious unstable and low pay jobs have negative impacts on immigrant families psychological material and physical health and wellbeing fathers unstable employment may also have a direct impact on their ability to provide care to their children with dds for example in precarious work environments it is unlikely that fathers will get support from their supervisors to skip job hours in order to attend their childrens health education or developmental services appointments economic and material constraints affect how parents manage and provide care to their children with dds for example basic practical tasks such as attending medical visits and doctor appointments may become an obstacle due to transportation limitations or lack of a valid drivers license for fathers this is of special relevance as new immigrant families may settle in peripheral areas of cities while services are mainly located centrally the intersection of migration status and access to services is determined by variables such as gender age class and ethnic background along with their economic exclusion or instability studies have shown that immigrant legal status determines the quality of and access to public services villegas argues that migrants with precarious legal status bhave insecure access to a range of goods and services that in canada are considered essential and linked to the basic rights and entitlements of citizenship even though health and developmental services for children with dds exist contingent factors such as fathers legal status determine their right to access and use services therefore as jennings et al argue bimmigrant status is itself a social determinant of health social isolation along with the above material and economic constraints the literature points towards new immigrant families experiencing social barriers for example immigrant families leave strong social networks in their home countries and therefore can feel isolated and alone in navigating through a new environment of services jennings et al explain that bsociety stigmatizes disabled children and views disability in childhood as a social problem and parents feel this strong stigma of their childs dd by their own support systemswho tend to blame the parents for the childs condition therefore immigrant families may be hesitant to readily seek out support in their new country of resettlement language and cultural barriers other important intersecting factors affect not only access to services but also act as barriers to immigrant fathers full enjoyment of the benefits of such services discrimination at the structural level is quite often felt by immigrant fathers who have children with disabilities experience with health care professionals has been highlighted as a barrier to care for immigrant parents who may view providers as superficial and uncaring they can feel alienated by the health care system mainly due to communication barriers and cultural differences the language barrier is one of the main obstacles in accessing receiving and utilizing health care services for parents of children who have disabilities for many immigrant fathers english is not their first language in addition medical language is in itself complex potentially leading to deficient communication between fathers and health care professionals this may impact on the ways fathers understand the condition and diagnosis of their children and may also prevent them from accessing and using necessary services for their children despite the use of translators families who have limited proficiency in english may still feel uncomfortable and frustrated trying to obtain information about their childs dd there is potential for miscommunication by health care professionals due to differing concepts of medical diagnosis and treatment immigrant fathers can often have difficulties in understanding the bwestern definition of their childs condition the medical reasons behind it and the treatment regime necessary according to greeson et al there is a subtle fear felt by immigrant parents towards western medicineas these beliefs may conflict with nonwestern ideals for example a childs disability in one specific culture may be viewed as a punishment from god rather than an entirely medical conditiona more spiritual perspective rather than medical therefore some immigrant fathers may be unwilling to accept the western medical diagnosis of a condition and may see their child as mislabelled this discrepancy can lead to a lack of knowledge about the childs condition and about the health care system including available programs and services finally another important factor is the process of acculturation for some first generation immigrant families families who migrate to a new country tend to preserve their unique cultural values norms and traditions the process of migration to a new host country comes with challenges in terms of adaptation to a set of differing beliefs ideologies and practices immigrant fathers may experience increased stress through this process having difficulty with relocating and adjusting to a new environment the pressures of adapting to a new culture along with taking care of children with dds increase the burden of care for these parents gender roles gender roles tend to shift for mothers and fathers after migration mothers become involved within the family in new ways through working earning money and playing a vital role in hospital visits and appointments this change in roles can bring stigma to fathers who are viewed within their own communities as not being strong and dominant in their family unitby not subscribing to traditional gender norms of being the family breadwinner balancing these external stressors can make immigrant fathers even more vulnerable as compared to nonimmigrant fathers table 2 summarizes the findings of this section as well as the number of relevant articles found within each thematic area discussion findings of this narrative review indicate that immigrant fathers of children with dds in canada are impacted across all houses four dimensions of social support immigration affects the availability of instrumental support for families due to underemployment and job insecurity following migration prevailing policies in the host country regarding access to services intersect with language barriers as well as with unfamiliarity of available services resulting in diminished structural support gender strongly impacts available emotional support for fathers in general and immigrant fathers in particular as fathers social networks are dually reduced due to their childrens dds and postmigration disruptions in family and friendship networks fathers of children with dds in general may perceive services are biased towards favoring mothers studies have associated the immigration process with health decline for immigrants after they arrive to canada raising children with disabilities can also negatively impact parents health this review supports the notion that while raising children with dds can be emotionally and physically challenging the task becomes more overwhelming when there is a lack of social support such as is the case for new immigrant families as jennings et al assert the main issue causing difficulty is not mothering children with disabilities but rather the lack of support for the parent caregiver new immigrants may not be aware of their basic rights to health and education and therefore may not necessarily seek out these resources for their child recommendations the following recommendations are proposed in relation to a income inequality and unemployment b access to health care social and developmental services c culturalsensitivity of health care social and developmental services and d participation of fathers reduce income inequality and unemploymentunderemployment the increasing wage gap and employment differential between immigrants and nativeborn populations are among the important policy issues highlighted in the literature teelucksingh and galabuzi show that in canada during the period 19962001 racialized groups and newcomers sustained ba double digit income gap and a higher rate of unemployment than nativeborn workers reitz also confirms that since the 1970s and until late 1990s immigrants employment rates and earnings have declined these groups are also overrepresented in precarious low paying occupations as walters et al explain the earning and employment gaps are important for immigrant populations in canada and around the world which has implications for entire populations promoting the insertion of immigrant workers in stable well paid and full time jobs will benefit immigrant families and the economy of the receptor country immigrants brepresent important economic social and demographic assets to their host country the exclusion of this population from the economy has negative impacts on both immigrants and the host country since the latter is not being benefitted from immigrants productivity and professional skills immigrants employment may also impose a burden for the host economy bfor dealing with poverty and its impacts on health and social wellbeing improve access to health care social and developmental services disparities in access to health care services are determined by gender age race income language and immigrant statusamong others the lack of equitable access to health care social and developmental services prevents disadvantaged groups to fully enjoy participate and exercise their rights as citizens scholars highlight the need to reciprocate the benefits that immigrants bring to the host society in terms of accessing to their entitled social benefits among the barriers identified to access health care services are language cost location transportation and culture policies in the host country shape the trajectories of inclusion and exclusion of its immigrant population therefore to reduce barriers to accessing health care social and developmental services for immigrant families raising children with dds as funders of these services government policies need to promote funding of inclusive practice strategies and equitable organization of delivery of services improve culturalsensitivity of health care social and developmental services health care social and developmental services professionals need focused education and training on providing genderappropriate culturally sensitive care for immigrant parents of children with dds targeted education should be given on how to interact with groups who have language barriers and help to empower parents to navigate through the multiple systems of services despite language and knowledge barriers it is still important for service providers to build rapport and trust with immigrant fathers in support of the optimal development of their children with dds for example health care providers should educate themselves on the economic and language barriers of newcomer immigrant families and gendered perceptions felt by fathers and take extra time to make parents feel comfortable this will create a better relationship impact the way parents perceive and interact with the health care system and ultimately benefit the health of the child familyfocused interventions have been suggested to benefit immigrant communities because of their focus on family behaviors and parenting styles it may therefore be beneficial to engage in a whole familyapproach when providing care to these communities research has also shown that home visits to families who have children with disabilities may be better for them rather than the hospital setting immigrant families can feel more comfortable at home and may not be as intimidated by medical professionals within their own home environments increase participation of fathers fathers who challenge traditional gender roles tend to be more involved in their childs life fathers who are actively involved with their child and who provide positive care and support have shown to benefit from the fatherchild relationship taking on nurturing roles for the child in a playful manner creates a stronger bond and increases positive family coping fathers who take on this bplaymate role as provider protector and observerhave better outcomes in terms of emotional satisfaction in addition to better outcomes for their child with dd and for the entire family it has been recommended for fathers to work as a team with their spouses rather than in a dominant manner to provide for their child by breaking these gender norms husbands and wives increase support for one another resulting in increased wellbeing social programs and services available solely for fathers are rare fathers report being ignored during family therapy activities having their wishes ignored and feeling excluded from the diagnostic processes for their child fathers can also feel anger towards receiving secondhand medical information as some health care professionals choose to disclose information to mothers without the presence of the father this lack of education leaves fathers feeling uncomfortable and causes them to distance away tailored counseling and support programs should be initiated for fathers only focusing on stress management techniques selfesteem education resources for coping and emotional expression such approaches have shown to increase father involvement in the care of the child as well as empowering them to feel significant in the family unit individualized counseling approaches for immigrant fathers may also be necessary recognizing the particular structural and instrumental social support barriers this population is facing limitations of the review the findings and recommendations of this review are limited in light of a number of caveats 1 the review integrated different types of dds without distinguishing between them as well as their level of severity and associated caregiving intensity for fathers 2 a specific search for the category of bsingle fathers was not conducted which may have provided us with the particular barriers faced in this context of parenting and caregiving of children with dds 3 immigrants were examined as one category however we recognize that migrants are not a homogenous group and 4 immigrant families specific pathways to canada and their prior home country experiences may differently shape their experiences with the canadian systems of support for families of children with dds it was not possible to individualize the review findings to this level of specificity due to a lack of sufficient numbers of ethnoculturally specific studies on immigrant parents of children with dds conclusion gender roles divisions of labor and parental responsibilities create unique experiences for both mothers and fathers most research has focused on the role of mothers as caretakers of children with disabilities and fathers have often been unobserved in this realm by conducting a narrative review of the literature we provide an analysis of the stressors and barriers experienced by fathers of children with dds in general and immigrant fathers in particular immigrant fathers experience additional stressors and barriers compared to their nonimmigrant peers due to postmigration related disruptions in social support future research is needed that unpacks broad categories of bimmigrant identity and dds so to translate findings into specific policies and practices also while most of the research to date has focused on the challenges of parents raising children with dds daytoday narratives of service providers and families point toward the tremendous resilience of parents in the context of raising children with dds future research is called for that documents the families agency in light of ongoing parentingcaregiving demands despite limitations of available social support

this narrative review examines research on the experiences of immigrant fathers raising children with developmental disabilities and considers the findings within the canadian context applying green johnson adams journal of chiropractic medicine 5 3 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 2006 methodology a stepbystep process was followed to conduct the review four databases psychinfo pubmed cinahl and sociological abstracts were used for the search a total of 39 articles were found to be relevant after applying the inclusionexclusion criteria also 20 articles from published reference lists and peerreviewed journal articles located through google scholar complimented the initial search along with houses 1981 four dimensions of social support an intersectional approach underpinned the analysis of findings four themes were identified which included economic challenges social influences cultural influences and the changing gender roles of fathers stressors and barriers to accessing health services in the postmigration setting were examined based on the reviews findings the paper recommends 1 addressing income inequality 2 improving access to health care social and developmental services 3 improving culturalsensitivity of health care social and developmental services and 4 increasing participation of fathers overall a more systemic understanding of immigrant fathers experiences is called for taking into account their multiple social locations

introduction magical realism has emerged as a distinctive literary genre particularly prominent in latin american literature this introduction serves as a gateway to exploring the fusion of magical realism and social critique within the works of two acclaimed authors gabriel garcí a má rquez and isabel allende in latin american literature magical realism transcends the ordinary interweaving elements of the fantastical with the mundane creating a narrative that blurs the lines between reality and imagination within this realm garcí a má rquez and allende stand as titans each wielding their unique brand of storytelling to dissect the intricacies of society and humanity the exploration of magical realism is not merely an exercise in literary analysis but an excavation of the sociopolitical landscapes that serve as backdrops to their narratives garcí a má rquez heralded as the father of magical realism and allende a voice of feminist empowerment utilize their narratives to unveil profound truths about power dynamics historical legacies and the human condition as we embark on this comparative journey we aim to unravel the threads of magical realism woven into the fabric of garcí a má rquezs and allendes works we seek to discern the underlying social critiques embedded within their narratives tracing the echoes of historical and cultural contexts that reverberate through their prose through this exploration we endeavor to shed light on the transformative power of literature to provoke thought challenge conventions and inspire change the worlds crafted by garcí a má rquez and allende beckon us to venture beyond the confines of reality inviting us to question reflect and reimagine our understanding of the world the concept of magical realism magical realism is a literary genre characterized by the seamless integration of fantastical elements into the fabric of everyday reality originating in latin america magical realism defies conventional narrative structures by juxtaposing the mundane with the extraordinary blurring the boundaries between the natural and supernatural realms at its core magical realism transcends simplistic categorizations embodying a multifaceted approach to storytelling that embraces ambiguity and paradox unlike traditional fantasy genres which often delineate clear distinctions between reality and fantasy magical realism interlaces the mystical with the commonplace imbuing the ordinary with a sense of wonder and enchantment the origins of magical realism can be traced back to the latin american literary tradition where authors such as gabriel garcí a má rquez isabel allende and jorge luis borges pioneered its exploration drawing inspiration from indigenous folklore mythology and colonial history these writers crafted narratives that served as reflections of the complex sociopolitical landscapes of their respective countries central to the concept of magical realism is its capacity to serve as a vehicle for social critique by infusing fantastical elements into their narratives authors engage in a form of allegorical storytelling that enables them to comment on pressing social issues historical traumas and power dynamics through symbolism metaphor and allegory magical realist writers offer nuanced critiques of societal norms and structures challenging readers to reconsider their perceptions of reality and truth magical realism therefore transcends the confines of literary convention offering a rich tapestry of narratives that defy categorization and challenge conventional modes of storytelling as we delve deeper into the works of garcí a má rquez and allende we are confronted with the transformative power of magical realism to illuminate the complexities of the human experience and provoke introspection on the nature of reality itself gabriel garcí a márquez magical realism as a tool for social critique gabriel garcí a má rquez often hailed as the master of magical realism utilizes this literary technique as a potent tool for social critique through his major works such as one hundred years of solitude and the autumn of the patriarch garcí a má rquez intricately weaves together elements of magical realism to unravel the intricate tapestry of latin american society and history explore garcí a márquezs major works one hundred years of solitude garcí a má rquezs magnum opus one hundred years of solitude is a sprawling epic that chronicles the rise and fall of the buendí a family in the fictional town of macondo set against the backdrop of political upheaval and societal transformation the novel explores themes of colonization imperialism and the cyclical nature of history garcí a má rquez employs magical realism to depict the surreal and the fantastical alongside the mundane blurring the boundaries between myth and reality through the lens of magical realism garcí a má rquez offers a critique of latin american society exposing the legacy of colonialism and the enduring effects of power and corruption the autumn of the patriarch in the autumn of the patriarch garcí a má rquez delves into the psyche of a tyrannical dictator in an unnamed caribbean nation through a labyrinthine narrative that spans generations garcí a má rquez explores themes of authoritarianism oppression and the cult of personality the novel is steeped in surreal imagery and symbolic allegory employing magical realism to evoke the absurdity and brutality of dictatorship garcí a má rquez critiques the abuse of power and the erosion of democracy offering a searing indictment of political tyranny and its impact on society in both works garcí a má rquez harnesses the power of magical realism to transcend the confines of conventional storytelling and delve into the depths of the human condition through his exploration of history politics and culture garcí a má rquez invites readers to confront uncomfortable truths about power dynamics societal inequalities and the cyclical nature of human folly in the following sections we will delve deeper into garcí a má rquezs use of magical realism as a tool for social critique examining the ways in which his narratives illuminate the complexities of latin american society and history analyzing garcí a márquezs use of magical realist elements for social and political critique gabriel garcí a má rquez employs magical realist elements as a potent literary device to critique deepseated social and political issues within latin american society his utilization of magical realism transcends mere storytelling it serves as a vehicle through which he unveils layers of societal complexities and challenges prevailing norms and power structures in garcí a má rquezs works magical realist elements often manifest in fantastical occurrences seamlessly interwoven with the mundane realities of life this blending of the magical and the ordinary allows garcí a má rquez to explore profound truths about the human condition and society at large symbolism and allegory garcí a má rquez utilizes symbolism and allegory to critique social and political issues for instance in one hundred years of solitude the recurring motif of the buendí a familys incestuous lineage serves as a metaphor for the cycle of violence and oppression perpetuated by colonialism and dictatorship the character of colonel aureliano buendí a embodies the disillusionment and futility of revolutionary ideals reflecting garcí a má rquezs critique of the failed promises of political upheaval magical realism as subversion garcí a má rquez subverts traditional narratives through the use of magical realism challenging dominant discourses and exposing underlying power dynamics in the autumn of the patriarch the dictators ability to defy death and manipulate reality through sheer force of will symbolizes the unchecked authority and impunity of autocratic rulers by blurring the boundaries between reality and fantasy garcí a má rquez forces readers to confront uncomfortable truths about political corruption and societal decay cultural critique and identity garcí a má rquezs portrayal of latin american culture and identity is deeply rooted in magical realism through vivid imagery and evocative language he captures the essence of latin american life while critiquing colonial legacies and cultural hegemony in works like love in the time of cholera garcí a má rquez explores themes of love desire and social hierarchy against the backdrop of a rapidly changing world shedding light on the complexities of human relationships and societal norms through his masterful use of magical realism garcí a má rquez transcends the confines of conventional storytelling offering profound insights into the social and political realities of latin america his narratives serve as powerful vehicles for critique challenging readers to confront uncomfortable truths about power privilege and the human experience in the following sections we will delve deeper into garcí a má rquezs literary techniques and their implications for understanding the complexities of latin american society examination of themes of power corruption and social injustice in garcí a márquezs works gabriel garcí a má rquezs literary masterpieces delve deep into the fabric of latin american society unraveling themes of power corruption and social injustice with poignant clarity through his evocative narratives infused with magical realism garcí a má rquez critiques the prevailing structures of authority and lays bare the inherent inequalities that plague his homeland in garcí a má rquezs works power emerges as a central motif often embodied by authoritarian figures who wield it with impunity through characters like colonel aureliano buendí a in one hundred years of solitude or the autocratic patriarch in the autumn of the patriarch garcí a má rquez portrays the intoxicating allure of power and its corrosive effects on individuals and communities alike corruption a pervasive force in latin american societies finds stark representation in garcí a má rquezs narratives whether its the exploitation of natural resources the abuse of political office or the manipulation of justice systems corruption seeps into the fabric of everyday life corroding the moral fiber of society garcí a má rquezs vivid portrayals of corrupt officials and complicit institutions serve as indictments of a system rife with moral decay social injustice another recurring theme in garcí a má rquezs works reflects the stark realities of life for the marginalized and disenfranchised from indigenous communities displaced by colonial conquest to peasants exploited by landowners garcí a má rquez lays bare the inequities inherent in latin american society through his narratives he gives voice to the voiceless shining a spotlight on the struggles of those trapped in the periphery of power through his exploration of power corruption and social injustice garcí a má rquez invites readers to confront uncomfortable truths about the societies they inhabit his works serve as powerful instruments of social critique challenging readers to reckon with the legacy of colonialism the pitfalls of authoritarianism and the enduring quest for justice and dignity in the rich tapestry of garcí a má rquezs literature themes of power corruption and social injustice intertwine to form a compelling narrative of latin americas tumultuous history and its enduring struggles for liberation and redemption as we navigate the labyrinthine corridors of his imagination we are confronted with the stark realities of a world where power often trumps justice and where the fight for equality and human rights remains an everpresent struggle isabel allende magical realism and feminist perspectives on social critique isabel allende a trailblazing figure in contemporary literature harnesses the power of magical realism to offer feminist perspectives on social critique through her evocative storytelling and vibrant characters allende navigates the complex terrain of gender power and identity challenging traditional norms and advocating for social justice exploration of allendes notable novels in the house of the spirits allende embarks on a sweeping narrative journey that spans generations weaving together the personal and political struggles of the trueba family against the backdrop of chilean history through magical realist elements allende imbues her characters with a sense of mythic grandeur blurring the lines between the mundane and the mystical the novel delves into themes of love loss and redemption while also offering incisive critiques of patriarchal structures and political oppression eva luna further showcases allendes prowess as a storyteller centering on the eponymous protagonist whose extraordinary life unfolds against the backdrop of a tumultuous latin american landscape through evas eyes allende explores themes of resilience survival and selfdiscovery while also shining a light on the struggles of marginalized communities the novel is a testament to the power of storytelling as a means of resistance as eva navigates a world shaped by violence injustice and inequality in both the house of the spirits and eva luna allende employs magical realism to subvert traditional gender roles and challenge societal expectations her female characters imbued with strength agency and resilience defy the constraints of patriarchy and carve out their own destinies in a world fraught with adversity through their journeys allende offers a vision of empowerment and solidarity inspiring readers to confront injustice and strive for a more equitable society by delving into allendes notable novels we gain insight into her unique blend of magical realism and feminist perspectives on social critique through her richly imagined worlds and indelible characters allende invites readers to embrace the transformative power of storytelling and to envision a future where gender equality and social justice prevail in the following sections we will delve deeper into allendes literary contributions and their implications for understanding the complexities of gender and power in latin american society analyzing allendes incorporation of magical realism to address feminist themes and social critique isabel allendes literary works serve as profound explorations of feminist themes and social critique intricately woven together with elements of magical realism through her masterful storytelling allende employs magical realism as a potent narrative device to illuminate the complexities of gender dynamics power structures and societal injustices allendes incorporation of magical realism serves to transcend the boundaries of conventional storytelling offering readers a lens through which to perceive the world in all its multifaceted glory by blurring the lines between reality and fantasy allende invites readers into a realm where the extraordinary coexists harmoniously with the ordinary enabling her to delve deep into the human experience and confront pressing social issues in works such as the house of the spirits and eva luna allende employs magical realism to explore the lived experiences of women in latin america offering a nuanced portrayal of their struggles triumphs and resilience in the face of adversity through the eyes of her female protagonists allende confronts entrenched patriarchal structures and challenges societal norms advocating for gender equality and social justice magical realism allows allende to infuse her narratives with a sense of wonder and enchantment creating spaces where the marginalized find agency the oppressed find voice and the silenced find liberation through allegory symbolism and metaphor allende addresses feminist themes such as female empowerment reproductive rights and sexual autonomy shedding light on the struggles of women across generations and cultures moreover allendes use of magical realism enables her to critique broader social issues including political repression economic inequality and cultural imperialism by interweaving elements of the fantastical with the harsh realities of life allende underscores the interconnectedness of individual lives with larger historical and societal forces inviting readers to reflect on the complexities of the human condition through her incorporation of magical realism allende transcends the constraints of traditional narrative forms offering readers a transformative literary experience that challenges perceptions provokes thought and inspires action her narratives serve as potent reminders of the power of storytelling to effect change to illuminate truths and to imagine worlds where justice equality and compassion reign supreme in the following sections we will delve deeper into allendes literary techniques and their implications for understanding feminist perspectives and social critique in latin american literature exploration of how allendes works challenge traditional gender roles and power structures isabel allendes literary oeuvre stands as a testament to her commitment to challenging traditional gender roles and power structures through the portrayal of strong complex female characters and the exploration of feminist themes through her works allende disrupts conventional narratives subverts patriarchal norms and empowers women to reclaim agency in a world shaped by entrenched inequalities in allendes novels female protagonists emerge as powerful agents of change defying societal expectations and reshaping their destinies in the face of adversity characters like clara in the house of the spirits and eva luna in the eponymous novel exemplify resilience courage and resilience challenging traditional notions of femininity and asserting their right to selfdetermination allendes depiction of female characters transcends simplistic stereotypes presenting women as multifaceted individuals with their own dreams desires and aspirations through their narratives allende explores the complexities of womanhood addressing issues such as autonomy sexuality and identity with nuance and empathy moreover allendes works critique traditional power structures that perpetuate genderbased oppression and marginalization by exposing the ways in which patriarchy operates to silence and subjugate women allende shines a light on the inherent injustices of a society built on hierarchical norms and discriminatory practices through her use of magical realism allende creates spaces where women can defy societal constraints and assert their agency in transformative ways whether through acts of resistance acts of solidarity or acts of selfdiscovery allendes female characters navigate a world fraught with challenges challenging the status quo and forging their own paths to liberation in allendes narratives the personal is political and the struggles of individual women mirror larger systemic injustices by foregrounding the voices and experiences of women allende underscores the interconnectedness of gender inequality with other forms of oppression including racism colonialism and economic exploitation ultimately allendes works serve as rallying cries for gender equality social justice and human rights through her vivid storytelling and unflinching portrayal of the human condition allende invites readers to imagine a world where gender roles are fluid power is shared equitably and justice prevails for all in the rich tapestry of allendes literature women emerge as catalysts for change challenging the status quo and reshaping the contours of history with their resilience strength and unwavering determination comparative analysis of garcí a márquez and allende gabriel garcí a má rquez and isabel allende stand as towering figures in latin american literature both renowned for their adept use of magical realism and their incisive exploration of social and political themes while their works share common ground in their utilization of magical realism they diverge in their narrative structures thematic focuses and cultural contexts garcí a má rquezs narratives often sprawl across generations and locales presenting intricate family sagas intertwined with the tumultuous histories of latin american nations his prose is characterized by its lush imagery and lyrical quality drawing readers into a world where the extraordinary is seamlessly woven into the fabric of everyday life through his use of magical realism garcí a má rquez critiques the abuses of power the corrosive effects of corruption and the enduring legacies of colonialism and imperialism in contrast allendes narratives tend to focus more closely on individual characters and their personal journeys within specific historical contexts her storytelling is marked by its intimate portrayal of human relationships and its exploration of themes such as love loss and resilience allendes use of magical realism serves as a lens through which to examine issues of gender identity and social justice with a particular emphasis on the experiences of women and marginalized communities while garcí a má rquezs works are deeply rooted in the political and social upheavals of 20thcentury latin america allendes narratives often reflect her own experiences as a chilean immigrant and exile both writers draw inspiration from the rich tapestry of latin american history and culture but their perspectives are shaped by their distinct backgrounds and personal histories despite these differences garcí a má rquez and allende share a common commitment to using literature as a tool for social critique and cultural exploration through their works they challenge conventional narratives defy literary conventions and offer profound insights into the human condition their legacies continue to resonate with readers around the world inspiring generations of writers and scholars to engage with the complexities of latin american literature and culture conclusion in conclusion the comparative analysis of gabriel garcí a má rquez and isabel allende illuminates the rich tapestry of latin american literature showcasing the diverse voices and perspectives that have shaped the literary landscape of the region through their adept use of magical realism garcí a má rquez and allende have captivated audiences with their vivid imagery compelling characters and incisive explorations of social and political themes garcí a má rquezs works transport readers to the mythical town of macondo and beyond where the boundaries between reality and fantasy blur and the human experience is laid bare in all its complexity through his narratives garcí a má rquez offers searing critiques of power dynamics corruption and the enduring legacies of colonialism inviting readers to confront uncomfortable truths about the societies they inhabit in contrast allendes stories invite readers into intimate worlds populated by resilient characters who navigate the complexities of love loss and identity through her use of magical realism allende explores the struggles of women and marginalized communities offering nuanced insights into the human experience and advocating for social justice and equality while garcí a má rquez and allendes works diverge in their narrative structures thematic focuses and cultural contexts they share a common commitment to using literature as a vehicle for social critique cultural exploration and human connection through their narratives they challenge conventional wisdom defy literary conventions and offer profound reflections on the human condition as readers journey through the worlds of garcí a má rquez and allende they are invited to explore the complexities of latin american history culture and society and to confront the enduring legacies of injustice inequality and oppression through their literary legacies garcí a má rquez and allende inspire readers to imagine new possibilities to question established norms and to strive for a world where compassion justice and empathy reign supreme in the end it is through the power of storytelling that garcí a má rquez and allende have left an indelible mark on the world of literature enriching our understanding of the human experience and reminding us of the enduring power of the written word to transform hearts and minds

this comparative analysis explores the themes narrative techniques and cultural contexts of gabriel garcí a má rquez and isabel allende two luminaries of latin american literature both authors employ magical realism to delve into social and political issues albeit in distinct ways garcí a má rquezs intricate narratives critique power structures and societal decay while allendes intimate stories focus on personal relationships and resilience despite their differences both writers share a commitment to using literature as a tool for social critique and cultural exploration

introduction in the wake of unprecedented ecological loss and social and political upheaval in recent years the fragile relationships that sustain human experience on this planet are perhaps more visible now than ever before with the understanding that these unfolding crises are inseparable from the model of social life made dominant by neoliberal capitalism and globalization postdevelopment discourse has increasingly pointed to the need for decoupling development from economic growth and to instead seek out alternatives to this end conceptual engagement with the pluriversea world with the ontological capacity for multiple worlds gestures to the possibility of a diverse matrix of alternatives rather than a unilinear approach to sustainable development ethnographic attention to how grassroots and localized alternatives to development are shaped by their geographic historical social and epistemic contexts has been instructive gesturing to the ways that communities societies and landscapes especially those dominated by industrial capitalism might be reimagined unmade or rebuilt by the same token i argue engagement with the pluriverse also entails revisiting the logical premises that have underpinned past approaches to sustainable development to develop a more capacious sensibility of what works in practice in keeping with the theme of this special feature on the pluriverse in practice this article discusses ecovillage communities in mexico to explore how different communities carve out spaces of possibility and flourish from within contexts shaped by global flows of extractive capitalism situated at the convergence of several transition discourses including cohousing commons thinking and degrowth ecovillages are broadly defined as communities that work to consciously pursue economic social and ecological sustainability through the harmless integration of human activities into the environment in a way… that is able to continue into the indefinite future as lópez and silva prada observe ecovillages seek to respond to social issues understood to stem from the environmental crisis andor the loss of meaning of the development model of contemporary capitalism seeking to enact change by living it ecovillages do not follow a particular blueprint or plan but instead coconstruct community values and practices in place these practices might include collectively growing food without pesticides or conventional fertilizers building homes and structures with locally sourced renewable materials or reducing energy consumption as such the ecovillage model has inspired academic attention to how it might be scaled up or imported to new contexts the question posed in the title of this articlehow do ecovillages workis directed towards this ostensible tension between autonomy and radical interdependence asking how ecovillage residents pursue alternative livelihoods while negotiating interconnectivities with the same broader economic and social systems they might be positioned against ecovillages are far from being islands of sustainability but rather remain deeply interdependent with the world beyond their boundaries both socially and economically as such residents simultaneously live in the ecovillage and the larger society as jonathan dawson former president of the global ecovillage network has observed ecovillage enterprises in common with all others in the capitalist economy depend on a culture of consumerism that far outstrips the meeting of basic needs moreover baker suggests that these lingering connections to broader systems can work to complicate or ultimately sunder communities after all the factors that these community founders are citinglending policies of financial institutions property values and zoning regulationscan be linked directly to capitalist processes and dynamics these considerations reveal the ways that the performance of alternative livelihoods requires substantial negotiation between sustainable visions and context or circumstance understanding ecovillages as kinds of exilic spaces or spaces on the margins of social and economic life in which people attempt to escape from capitalist relations and processes i ask how ecovillage communities renegotiate their relationships to the broader social and economic systems in which they are entangled drawing on ethnographic research conducted in two ecovillage communities in two states in mexico i call attention to instances in which interlocutors engaged with the concept of rentabilidad in the contexts of the regenerative agricultural systems and community spaces they construct building on understandings of relational value i problematize the normative associations between profitability on the one hand and the perceived viability of alternative community models on the other undoing these connections involves attending to the socially constructed dimensions of profitability and the different ways that profitunderstood here as the return of advantages or benefits relative to the time labor attention or resources investedis reconfigured particularly in relation to morethanhuman lives this article is structured as follows i first develop a theoretical understanding of rentabilidad through a morethanhuman lens explaining how this idea complicates existing approaches to economic sustainability i then trace this argument through the particular contexts in which ecovillage communities in mexico are situated identifying three ways in which relationships with morethanhuman others influence the ways that ecovillages work finally i relate these examples back to the broader discussion of the pluriverseinpractice touching on how ecovillage communities collectively reframe practices in relation to broader values morethanhuman understandings of rentabilidad while economic sustainability has long been enshrined as a key dimension of sustainable development discourse scholars have highlighted how a persistent conceptual ambiguity has complicated attempts at putting it into practice owing partly to this undertheorization conventional economic logic continues to underpin the way sustainability is framed in particular the assumption that markets are inherently driven by profitable growth as spangenberg notes continuous and indefinitely sustained growth isoften implicitlyassumed to be part of sustainable development of the economy in mainstream policy debates this framing has a distinct influence on the way sustainable development is pursued based on the unquestioned understanding that economic vitality is a necessary precondition for increasing living standards or fostering social improvements economic growth has come to be framed as tools for furthering both social and ecological sustainability objectives the understanding that people planet and profit are commensurate and mutually achievable objectives has been further reproduced through the emergence socalled hybrid organizations or social enterprises business models that have sought to realign profit with social impact and environmental responsibility the unexamined premise that profitable growth is a necessary condition for achieving sustainability outcomes is problematic for several reasons first scholars have pointed out that enterprises oriented towards profit maximization and capital accumulation simultaneously drive environmental damage and social inequality alongside economic growth revealing the inherent paradoxes of using the former in the service of addressing the latter second scholars have increasingly demonstrated how conceptions of value encoded in measures of profit are socially constructed and relational for this reason reframing profit as an objective that can be attained through the adoption of more sustainable practices still fails to offer an explicit critique of the valuecreation logic that underlies these conventional understandings of what profit is or how it might be attained finally scholars have increasingly called attention to possibilities for living well that do not hinge on profit or economic growth examining diverse expressions of communitarian and grassroots approaches to sustainable livelihoods or speculating how a downshift to notforprofit business models could facilitate postgrowth transitions in short conflating profitability with viability consigns us to a narrow interpretation of what works and what does not limiting the scope of alternative socioeconomic models considered though profitability is a contested term i use it here to refer to a constellation of labor value and time expended in such a way that it produces a gainful yield although profit is normatively associated with capital conversations with ecovillage residents revealed the ways that this concept was reconfigured to account for ecological and social as well as economic abundance this analytical focus was particularly inspired by a conversation with an ecovillage resident named katrina where she described her vision for the future of her community the point is to be autónoma thats the idealiberty not to just be sustentable or autosustentable like making money through workshops eating our own food…but a project also has to be rentable when encouraged to explain further i was surprised by her answer not just making money of course but also politically rentable… socially rentable to help to make things better but to still live simply this exchange gestured to the subtle ways that seemingly neutral economic language could be reframed and suffused with new meaning to align with community objectives neither of the communities discussed here could be considered conventionally profitable instead katrinas reflection suggested the possibility for fundamentally remaking the rubric by which community successes were evaluated not by profit as a standardized unit of value but rather localized and collectively negotiated sensibilities of rentabilidad in focusing on these qualitative shades of rentabilidad i engage with ongoing streams of discourse from environmental studies anthropology and ecological economics that have sought to understand how alternative values are relationally constituted between humans and morethanhuman others as saxena et al argue greater sensitivity to morethanhuman actors in qualitative research has revealed the complex ways humans inscribe meaning on morethanhuman bodies through practices of labor and care and how these relationships coconstitute one another such an approach considers morethanhuman beings as creative agential forces or rather as ends in themselves and not just means to human ends this relational value perspective emphasizes ways that humans make meaning and assign value to their environment and other living beings in ways that extend beyond instrumentality understandings which are not only forged through labor and productive relations but rather are reflective and expressive of care identity belonging and responsibility and congruent with notions of what it means to live a good life engagement with different practices of alternative agricultureincluding biodynamic agriculture permaculture and agroecologybecomes ways of enacting contestations in the fields and in doing so performs alternative rural realit ies of mutualism and abundance turning attention to the ways that ecovillage residents design and maintain networks of multispecies relationships reflects underlying values of particular communities but also how these values are negotiated by residents through their daily practices methodology and research sites this research draws on participant observation and ethnographic fieldwork carried out over approximately 13 months in ecovillages throughout mexico between june 2018 and november 2019 for purposes of salient comparison i focus on two communities aldea ceiba in the state of yucatán and rancho bosque rancho escuela in veracruz1 i spent approximately 4 months divided into two periods during different seasons serving as a volunteer in both communities this arrangement of working in exchange for accommodation allowed me to live in residence with both communities and develop familiarity with interlocutors this role also allowed me to work with and alongside residents in roles that ranged from preparing communal meals harvesting crops cleaning stables or tending to compost piles alongside different residents moving between communities allowed me to be present for important community events or to observe differences in priorities and work practices at different times of the year aldea ceiba community was founded in 2015 outside of a small community in central yucatán by a group of approximately 9 residents and a continuously rotating community of volunteers visitors and friends the tropical climate permits the cultivation of diverse agroforestry systems informed by regenerative agricultural practices such as permaculture or syntropic agriculture an approach to cultivating agroforestry systems by mimicking forest succession cycles the community describes itself as a center for the interchange of knowledges and in addition to experimenting with local agricultural techniques and ecotechnologies they also held workshops and community gatherings on topics such as native bee conservation or recuperating traditional milpa farming systems residents often earn an income from their own projects within the community although incomes are partially pooled and redistributed to particular members as needed a beekeeper in aldea ceiba for instance might keep the proceeds from holding paid workshops on bee care while honey sales might be directed back to the community the second community rancho bosque lies adjacent to a protected cloud forest on the outskirts of a large urban center in veracruz and comprises several pastures and shadegrown orchard spaces as well as patches of native forest the community ranges in size from five to twenty people at any one time composed of permanent residents apprentices who live in the community for several years as part of a livein educational program and foreign volunteers rancho bosque predominantly practices biodynamic agriculture a form of organic agriculture with elements of spirituality and folk practices that has roots in central europe a printed vinyl sign hung at the entrance to the communitys land summarizes the key message the founders hoped to impart to the young apprentices and visiting students you can and should be proud to practice the most important profession that exists to work the land to raise animals to take care of the environment the forest the soil the water without you without agriculture there would be no known development culture would not have developed and without this no known civilization be proud of yourselves the ideological emphasis on selfsufficiency is connected deeply to their work with livestock although they also maintain gardens grow shadegrown coffee and macadamias and have a small dairy and bakery although occasionally animals are sold to neighbors or other local farmers the primary focus of caring for livestock is in developing practical education programs for young apprentices who live on site over the course of several years to learn how to manage their own holistic agriculture projects on the surface these communities differ substantially from one anotherlocated in distinct ecological and geographic contexts they have different and at times contradictory approaches to issues ranging from agriculture to styles of conflict resolution at the same time both communities share similar concerns for the future livability of the planet brought about by consumptiondriven capitalism pollution deforestation and loss of biodiversity both communities practice forms of subsistence organic agriculture rely on forms of renewable energy build homes and communal spaces with local or biodegradable materials and seek to reduce or relocalize consumption to the greatest extent possible i carried out indepth participant observation and semistructured interviews with residents visitors and volunteers asking participants to reflect on their roles in the community and how they went about their daily routines while residing in these communities i attended and documented evening lectures cultural events and workshops on topics such as soil care bee care and holistic veterinary practice in particular i sought out opportunities where human residents interfaced with the animals plants insects and other species present in their communities by following patterns of daily work helping with tasks such as checking beehives cleaning stables cultivating and maintaining gardens or planning the rotation of crops and livestock in the ecovillage landscapes providing rich opportunities for understanding how residents conceptualized value in relation to their work with morethanhuman others2 fieldwork notes and informal encounters and conversations also contribute to the understandings discussed in this article resistance in place situating mexican ecovillages the emergence and popularization of the ecovillage community model in mexico must be understood in relation to increasingly neoliberal and industrialized approaches to rural development in mexico over the last century following the mexican revolution of 1917 over onehalf of mexicos arable land was redistributed to indigenous communities and groups of smallholders who were given usufruct rights to communally held lands known as ejidos 3over time however smallholder agriculture came to be compared disfavorably to the efficient largescale modern farms that were ushered in by the green revolution and spending on rural infrastructure increased greatly in the early 1940s state support subsidies and highyield seeds were increasingly directed to these larger agricultural enterprises in an effort to spur economic development through exports in 1992 an amendment to the mexican constitution permitted the private sale of ejidal lands and helped pave the way for the adoption of the north american free trade agreement in 1994 effectively ending state support for the ejido each of these developments reflects pieces of a common central narrative shaping rural development policy in mexico in the last decades namely the conversion of informal smallholder economies into an agricultural sector through industrialization and privatization selfsufficiency and autonomy have been common conceptual threads of the social and environmental movements premised on resistance to these policy developments carruthers discusses how indigenous and environmentalist movements became linked in their mutual resistance to structural policies that prioritized economic development at great cost to the socioeconomically vulnerable and the environment this has perhaps been most notably exemplified by the mobilization of the zapatista army of national liberation an autonomous movement that emphasized indigenous rights and food sovereignty the day that nafta came into effect as barkin notes these developments produced a range of grassroots alternative development models with more communities forging alternatives that allow them greater autonomy and experimenting with new productive combinations that allow them to strengthen their communities in such a way traditional practices of agriculture landscape management and species care have also become forms of resistance in and of themselves as alliances between indigenous rights and environmentalist groups both center on the effort to preserve and defend traditional ecological knowledge communities like rancho bosque and aldea ceiba locate their broader community objectives at the intersection of these discursive threads of resistance albeit in different ways while founders at rancho bosque hoped to combat the decline of smallholder agriculture by providing training and resources to local youth interested in managing their own holistic farms and ranches aldea ceiba residents collaborated closely with maya neighbors in maintaining the health and biodiversity in their agricultural systems similar to other ecovillage projects that have been documented elsewhere many residents come from largely uppermiddle class and urban environments longterm visitors and volunteers to rancho bosque and aldea ceiba are a mix of foreign nationals from north america europe and latin america as well as mexican nationals the founder of the rancho bosque community was raised in europe while aldea ceiba was composed largely of a group from mexico city and surrounding environs foreign ecovillage founders benefitted from access to foreign passports pensions and healthcare plans while enjoying a relatively lower cost of living on the strength of foreign currencies although foreigners are not able to own ejido land outright informal contractual andor good faith agreements with mexican residents extend the circle of de facto stakeholders in the community these arrangements rely heavily on trust amongst community members and can be tenuous or unstable 4 at times these differences were recognized and explicitly worked against in aldea ceiba for example the amount of requested donations for volunteers from mexico and other latin american countries was lowered relative to that of other foreign volunteers due to recognition of the socioeconomic imbalance between visitors and volunteers from differing backgrounds despite the fact that community residents are oriented towards the goal of selfsufficiency both communities retain dependencies on the outside world to support their communitys activities both rancho bosque and aldea ceiba rely heavily on the labor of volunteers and visitors in caring for animals managing cultivated areas leading workshops or preparing artistic or cultural events cooking communal meals or other key tasks both communities advertise their projects on online portals such as wwoof or workaway in search of volunteers many of whom are foreign travelers with interests in environmental or social activism and or sustainable agriculture many foreign volunteers contribute labor in exchange for modest accommodation and meals sometimes contributing a nominal fee for expenses incurred additionally several residents in rancho bosque and aldea ceiba from mexico received funds from a new nationwide social program known as jóvenes construyendo el futuro which allows young people who are not working or studying to ally themselves to participate in various forms of employment training with different companies or civil society organizations together each of these sources of funding and income was instrumental to supporting each communitys fluctuating population of volunteers and visitors and was an important supplement to subsistenceoriented agricultural practices ecovillage residents in both communities rely heavily on their cultivation of various plants animals and insects both for selfconsumption and for outside sale rancho bosque sells a variety of products in a small storefront at the edge of their property and at local markets in the nearby capital of xalapa these include valueadded products like cheese and dairy products or baked pastries as well as specialty staples such as coffee nuts or honey at aldea ceiba different kinds of honey as well as specialty products like medicinal tinctures and locally produced handicrafts were sold in a small shop located on site or distributed to specialty shops in nearby cities or through residents social networks the relative lack of a local market for ecologically produced specialty products is in part a function of the location in rural areas in which ecovillage communities tend to be located which are by and large areas where local consumers are unlikely to be able to afford them complicating attempts at integration into local markets while caring for morethanhuman others is and has long been a part of rural livelihoods ecovillage communities differ from other kinds of traditional or agrarian communities in two primary ways first new ecovillages are largely products of intentional design and as such seek to selfconsciously organize social and ecological relationships in harmonious ways agroecological systems are often premeditatively designed with the goal of creating selfsustaining systems which are maintained in ways that are seen to mimic ecological or natural processes second many ecovillage residents have little or no prior practical experience in agriculture or the ecological contexts in which these communities are founded as such the process of maintaining agroecosystems implies a highly experimental and collaborative approach in their design relying on relationships with local experts practitioners and neighboring communities in this way ecovillage residents are not necessarily novel in their approach to agriculture but rather exhibit novel ways of relating to or engaging with forms of indigenous or traditional land management practices and agricultural strategies in the service of constructing new livelihoods the importance of these social relationships became apparent in aldea ceibas response to the dual crises affecting communities in yucatán in early 2020 devastating flooding caused by tropical storm san cristóbal and the covid19 pandemic both damaged crops and prevented workers from taking up regular means of employment largely in the tourism sector in nearby coastal cities in response two residents of the aldea ceiba community founded an initiative to provide resources for local families to cultivate traditional home gardens for selfconsumption funded in large part from donations of past volunteers solicited through online social networks as well as regional organizations with whom they had previously collaborated the project which aims to address economic and food insecurity draws on the alreadyembedded relationships ecovillage residents have built within neighboring communities by pooling resources to enable local families to develop homescale cultivation of traditional crops in the words of the project leaders we have woven intercultural relationships based on respect and cooperation with various families which today allows us to have the conditions to develop this new project that links food sovereignty the regeneration of community relations along with the work of the land and the flourishing of women as leaders for the cultural transformation that we need around the world today in the sections that follow i build on this contextualization by highlighting the ways that ecovillage residents construct and negotiate understandings of value in relation to their work with morethanhuman others using rentabilidad as an orienting concept to capture processes of value construction i explore how residents of aldea ceiba and rancho bosque mediate and refine community goals in relation to morethanhuman entities through three dimensions alternative relations of scale alternative values and alternative temporalities alternative relations of scale one of the ways in which ecovillage residents renegotiate understandings of profitability is by reconfiguring the scale of their activities around morethanhuman lives past approaches to sustainable community development have been often oriented towards transforming rural communities into adaptable networked market actors for rural communities to succeed in the global economy it was reasoned they must be able to compete not only with other rural communities both at home or abroad but also with urban areas as tsing argues framing scalability thusly requires homogenization in that it requires a project to change scales smoothly without any change in project frames and as such that project elements be oblivious to the indeterminacies of encounter the imperative to scale up is often incongruous with the objectives of communities like rancho bosque and aldea ceiba however which seek to scale back consumption practices and instead resituate livelihoods within local ecologies rather than working to build economies of scale that also happen to be ecological residents instead reframe relationships with external sources around community residentsboth human and not residents at rancho bosque and aldea ceiba both expressed that a key goal was to recenter consumption practices around what the community was able to produce rather than vice versa in both communities raising livestock or cultivating gardens was primarily understood to be for consumption within the community rather than for sale might not be wholly attainable the conceptual benchmark was frequently invoked nonetheless in community discussions about consumption habits in the dining room of rancho bosque hung a sign with the title achieving a society without war fear hunger and with better educationwhat do we have to do to bring us closer to our dreams the list of key principles below urged residents to reconsider their consumption patterns dont be blackmailed by the pressure to buy a certain type of clothes a phone a drink or some junk food…the true happiness will be had by the one who has produced the items not necessary for your life while not all community members share the same ascetic zeal orientation towards the broader goal of selfsufficiency has still inspired some communitywide changes in consumption patterns manu a longtime resident of aldea ceiba reflected how the communitys dietary patterns had shifted in relation to the challenges of growing particular crops in the nutrientpoor soils of the yucatec forest now we experiment a lot more with native seeds and plants because thats what we havethe things were meant to eat in this environment among the communitys most successful experiments were recipes shared by neighbors or inspired by staples of mayan cuisine such as balché a fermented alcoholic drink made with honey or bread made with the flour from the nut of a ramón tree the immense value of this local knowledge could not be underestimated one of the founders of the community emphasized to me we nurture those relationships with our neighbors in good faith because without them we wouldnt be here while volunteers and paying visitors are essential in helping ecovillage communities run smoothly permanent residents often prioritize the integrity of ecological systems over accepting more paying guests and volunteers expressing these limits in terms of morethanhuman actors in aldea ceiba one resident who was tasked with giving tours to newcomers often paused at a shady grove of mangoes located off the forested trail to the meditation platform we love having volunteers but sometimes it is too much we are surrounded by water but all of it here in yucatán its underground said the resident referring to the belowground channels and pools formed in the karstic limestone bedrock of the region these mangoes are our guide for when to stop accepting new people when we have too many peoplethirty people or moreespecially in the dry season these trees will start to droop he told the group emphasizing his point by frowning and mimicking limp unwatered leaves with his arms likewise rancho bosque paused their volunteer program for several months following the death of several sheep in their herd even declining offers from paying visitors the resident in charge of managing livestock rotations explained that the decision was based on the perception that the general health of the flock always seemed to take a dip when new volunteers were present volunteers not only required training and consideration but also brought unpredictable energies that had the potential to disrupt the subtle rhythms of the flock the cascading effects perceived to stem from this lack of attunement to animal energies could have significant consequences both for the integrity of the products they hoped to sell as well as the survival of the flock itself engaging with morethanhuman actors in particular ways also opens up and facilitates particular avenues of financial support both rancho bosque and aldea ceiba were registered as asociaciones civiles a particular kind of registered civil society notforprofit association registration as an ac allows ecovillage communities to formalize aspects of their work including the foundation of educational programs in regenerative agriculture or sustainable pasture management or organizing and promoting cultural events additionally such affiliation allows ecovillage communities to legitimate external forms of support for example from governmental funds for the development of regional culture development institutions or private individuals in particular rancho bosque was supported by a german development fund focused on promoting biodynamic agriculture particularly in developing countries similarly the work of two community members of aldea ceiba on the topic of native bird conservation brought their community into contact with local conservationists who provided resources for initiating a youth club in the local community dedicated to birdwatching and engaging in waste management and conservation activities ultimately these relationships culminated in a program through which selected students from the community group were invited to the united states to participate in an outreach program offered by a renowned biological research institution in this way residents assembled networks of external collaborators and supporters through their work with particular kinds of species or agricultural practices using these associations to root in place rather than expand outwards alternative values by alternative values i refer to the ways that ecovillage residents seek to reframe community goals in relation to morethanhuman lives as kasper observes what distinguishes the ecovillage paradigm is an expanded notion of community one that includes not only people but countless other species as well through this acknowledgement of self in relation to interdependent parts and processes of the living systems which support the community ecovillage residents conceptualize the value of their work with other species in ways that transcend strictly economic benefit residents in different communities identified strongly with their roles working with particular species although residents in both communities had broad knowledge across various domains of community agricultural operations individuals gravitated towards particular roles either through selfselection or through rotating assignments relationships formed in these daily roles contributed to the formation of particularized kinds of knowledge that could have only been generated through regular experiences relative to this fulltime schedule with few days of vacation the cash with which residents were provisioned monthly was paltry when asked about this discrepancy however i was surprised to hear that many residents felt the exchange was fair im not working for the farm manager and im not necessarily working for the salary said one young farmhand who had lived in the community for nearly a year caring for their herd of sheep instead this resident expressed a deep commitment to the land and his flock and highly valued the opportunity to gain experience in different ecological farming practices without assuming the financial risks of land ownership himself relationships forged with particular morethanhuman others draw residents into care relationships with still other species as one shepherd told me of his work with the sheep i call myself a pastor but actually i am really engaged with praticultura referring to the fact that he spent most of his days not with the sheep but rather managing the communitys parcels of pasture this is to say that focusing on the health of sheep meant also attending to the sheeps web of relationships with soil parasites and native vegetation this practice of nested cultivationcaring for particular beings like grass with the understanding that their care will have ancillary effects for other valued beingsshows how understanding the broader ecological and social role of individual animals or plants influences the way that work is undertaken in the aldea ceiba community this was evidenced by their dual cultivation of several species of native bees as well as apis mellifera the european honey bee beekeepers in aldea ceiba community cultivated habitats for native bees both directly in caring for and managing hives of particular species and indirectly by cultivating native vegetation pollinated by specialist bees or by actively conserving existing native bee nesting sites around their land in doing so community residents actively participated in the conservation of endangered native species particularly those which were of cultural significance to the local communities while both produce honey apis mellifera produced far more honey by weight per hive than did melipona beecheii caring for apis mellifera bees enabled aldea ceiba residents to care for melipona beecheii bees in that revenue generated from both workshops and the sale of bee products allow ecovillage residents to continue cultivating melipona beecheii hives the cultivation of native bees however transcended their utility as a species that produced a marketable product rather cultivating melipona bees allowed the community residents the ability to engage on a material level with local communities particularly local beekeepers this engagement with native bees also implicates community members in the broader discourse of indigenous land tenure and dispossession and the survival of cultural traditions because it is rare to encounter melipona beecheii hives outside of human cultivation the hives that aldea ceiba tends to are divisions from hives borrowed from their neighbors at the same time honey produced by the apis mellifera bees was used to sustain the ongoing conservation work that the community had organized around native bees not only did income from the sale of apis mellifera honey help to fund the construction of more apiaries for native bees but apis honey was also used as a way to feed native bee colonies during the wet season when food stores are low these material relationships are underscored by the relationships that the communitys beekeepers construct and maintain with the hives they care for over time one founding resident became the communitys beekeeper over time after encountering the native melipona bee for the first time developing an affinity for the calm species5 that seemed to mirror her own personality participating in external beekeeping conferences and workshops held at a local agroecology school allowed this resident to deepen their understanding of the differences in caring for native bees as opposed to the more widely known apis mellifera species and also to become conscious of the species precarious future 6mindful that any honey harvested from the melipona bee represented a possible drain on the health or energy stores of the hive the beekeepers only extracted small amounts of honey using a hollowtipped syringe to draw the honey out of the pots the bees stored it in instead of slicing them open with hot knives by respecting the work of the bees themselves the resident reasoned the bees would hopefully flourish to return the favor in kind alternative temporalities a third angle through which ecovillage residents unmake conventional understandings of profitability is by unmaking relationships between time and value what kolinjivadi et al call alternative escape temporalities or time scales that resist capitalism through incongruity in capitalist systems time is conceived of as predictable homogenous linear… and endlessly unfolding and this understanding is performed in conventional agrienterprises in a variety of ways accelerating food production manipulating seasonality or privileging modern or technologically intensive techniques on the other hand scholars have documented how grassroots movements and local communities construct counternarratives critiquing and remaking relationships between value and the passage of time at rancho bosque and aldea ceiba evidence of these renegotiated understandings is influenced by relationships with morethanhuman residents in two senses first by synchronizing patterns of work to the liferhythms of morethanhuman others and second by recasting the value of expended labortime in terms of net benefit to the community as a holistic system in seeking to contest what they framed as a cultural loss of connection with land ecovillage residents consciously adopted practices and styles of working that took into account seasonality and ecological cycles taking time to work properly with the animals and plants they cultivate involves organizing work activities around morethanhuman timescales this was evidenced in part by the rotational grazing system implemented by rancho bosque through which the movements of animals through particular pastures was carefully orchestrated so that no animal reentered the same parcel twice in a month span such rotations reflected both the life cycle of pasture grass and the time it took to reach optimal height for regrazing as well as the life cycle of intestinal parasites present in recently browsed pastures while such rotational practices demand more time and direct management by shepherds such systems were seen as the only logical profitable movein that neglecting this balance could permanently degrade soils working on smaller scaleswith fewer hands and resources than conventional operations for instancenecessitates much greater individual investments of labor and time however many residents reframed these investments of time as the opportunity cost for the multiplied benefits of living in community one evening i found a young shepherd named alejandro in the panadería where he had been scraping bits of meat from the skull of a slaughtered ewe while chatting with a friend earlier in the day a visitor to the communitys storefront had inquired about the price of purchasing mutton and i posed the question to alejandrosurely the amount of time and attention devoted to processing the carcass would be reflected in the meats price at market he grinned wryly and explained it was quite the opposite slaughtering the ewe had taken nearly all day and he was only completing the task 1 3 by evening firelight without even accounting for the time he had devoted to all that managing the sheep flock entailed there would be no point to sell the meat still he considered his work more than worthwhile what we have here is enough for us to eat well he said referring to other residents visitors and volunteers for my time its worth it for us but not to sell it closer attention to factors such as seasonality and morethanhuman lifetimes resulted in a diversification of economic practices as profit was generally understood to derive from the whole of community landscapes and morethanhuman residents in concert rather than the particular components or beings comprising those systems at rancho bosque coffee and macadamia nuts were harvested intermittently throughout their fruiting cycles while young pigs or lambs were butchered and sold as individuals came to maturity or when herd populations began to outstrip available pasture space in community meetings at aldea ceiba residents were encouraged to gather particular kinds of native seeds or fruits at their leisure as they came into season tufts of cottonlike fiber from the seed pods of the ceiba tree that often blanketed the ground in march or the edible seeds of the pich or pixoy trees 7 because processing seeds was extremely timeintensive but required little concentration this work was often folded into leisure time small groups of residents inevitably formed in the communal palapa around piles of hulled seedpods especially in the midday heat of the dry season working alone the work of prying small seeds from their hulls was considered hardly worth doing because of the time required to produce an amount of any significance as a collectively performed pastime however the work became worthwhile one particular experience working in rancho bosques garden spaces reflected the differences in how residents understood the expenditure of their time relative to resultant benefits after preparing beds for the transplantation of seedlings the gardener whom i was working alongside enlisted the help of two apprenticeshepherds and myself to dynamize the water we would supply the plants with after planting8 for the next hour myself and three residents would stand huddled around the blue plastic rain barrel stirring the water in a clockwise motion with a long broad stick as soon as the water began to swirl around the edge of the barrel creating a tunnel that extended nearly to the bottom the stirrer would heave the stick back and begin stirring in the opposite direction the force necessary to whip the water one way and then another was exceedingly difficult to sustain for any great length of time and we passed the stick between us every few minutes as we stirred the water with the goal of bringing downwards the energetic forces from the air into the water that would be used to germinate new seedlings i considered briefly how such a task would be rendered absurd in an industrialized agricultural system where time is money under such assumptions a task that absorbed the attention of four workers for the course of an hour could hardly have been considered productive at the end of the hour when the trail of water began to slow he cupped a handful of the water out of the bucket and observed it the water feels softer now he says explaining that the change in color and texture indicated that the bodies of microorganisms in the water had been broken up by the force of the vortex the water was sufficiently energized now he explained and ready for application on the new seedlings to be planted in accordance with the new moon that would be occurring that month when prompted the gardener explained the value of taking time for caring about seemingly mundane details was one of the privileges of working in smaller scale agricultural systems we have time to bring the energy in to care about the energywere not trying to produce as much as we can the experience revealed how the performance of alternative relationships with time constituted a central part of putting the communitys vision into practice instead of inefficient slowing down and paying attention are framed as strategies for doing more with less focused on producing better quality livelihoods on their own terms conclusion this article has worked to trace how ecovillage residents attempt to make their respective communities into a shape that cannot so easily be appropriated by a capitalist value system… by changing the frame of reference by engaging with qualitative examples of how rancho bosque and aldea ceiba residents express understandings of rentabilidad in relation to morethanhuman residents i outline how changing terms articulates with changes in practice in particular these cases reveal how cultivating an expanded understanding of value in relation to daily practices of work helps ecovillage residents to make sense of and subvert latent interdependencies on broader capitalist systems these examples reveal paths forward in the sustainable development discourse and suggest the generative possibility of revising the conceptual rubrics against which alternatives to development are compared insisting that ecovillage communities be formatted as models glosses over the complex daily negotiations that occur in the experimental and marginal spaces that seek to position themselves against the status quo removing the expectation that alternatives be profitable in a colloquial sense allows us to understand ecovillage projects as sites of productive experimentation rather than scalable models instead reflecting on the shifting malleable relationships between time capital and value reveals how these relationships might be reimagined or remade what this article works towards instead is an understanding of the success of such projects on their own terms rather than on capitalcentric or growthbased rubrics rather following tsing i understand the language of scale to be incompatible with understanding alternatives in practice understanding how ecovillage residents grapple with these contesting currents is useful not because they provide models to replicate but rather paths of resistance to follow funding open access funding provided by central european university private university funding was provided by central european university open access this article is licensed under a creative commons attribution 40 international license which permits use sharing adaptation distribution and reproduction in any medium or format as long as you give appropriate credit to the original author and the source provide a link to 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this article highlights the emergence of intentional communities known as ecovillages ecoaldeas in mexico exploring how humans seek to design sustainable futures in part by remaking rural livelihoods ecovillages are inherently speculative ventures or as burke and arjona 2013 note laboratories for alternative political ecologies invitingand indeed necessitatingthe reimagination of human lives with greater consideration for the natural world in this sense such communities might be understood as exilic spaces ohearn and grubačić 2016 in that they seek to build autonomous and selfsustaining agricultural social and economic systems while also reflecting a stance of resistance to neoliberal capitalist structures at the same time communities may also remain dependent on connections to broader regional or global markets in diverse and interconnected ways understanding ecovillages as diverse and emergent worldings de la cadena and blaser 2018 i ask how these experimental social ventures reckon with their connections to the very systems they are positioned against to trace out how communities negotiate this fragile space this article is concerned with how ecovillagers spend their time at workparticularly when it comes to managing relationships with and between morethanhuman beings drawing on participant observation with ecovillagers and morethanhuman others they work with i explore how the concept of rentabilidad profitability is differently constructed to this end i highlight ethnographic examples where rentabilidad is purposefully reconceptualized with morethanhuman lives in mind such a shift i suggest hinges on ecovillagers individualized relations with the beings they imagine themselves to care for

introduction on 27 july 2021 the first olympic medals for the sport of surfing were awarded on the sands of tsurigasaki beach in chiba prefecture japan standing on the podium were team japans silver medalist kanoa igarashi and bronze medal winner amuro tsuzuki surfing was included alongside skateboarding and bouldering by the international olympic committee in the tokyo 2020 games with the aim of attracting a younger audience 1 in japan it was hoped that the olympics would professionalize the sport of surfing demonstrating its economic and social contribution while also legitimizing the role of surfers in broader japanese society 23 this olympicinspired professionalization of surfing in japan is creating new conditions of possibility for surfing to become institutionalized in new and interesting ways but empirical research detailing this process is limited one important way that surfing is being institutionalized in japan is through its incorporation in the public educational system the arrival of lifestyle sports in the olympics comes at a time when encouraging youth to engage in physical activity has never been more pressing the world health organization 4 reports an increasing prevalence of obesity prolonged sedentary behavior and overall declining levels of physical activity among youth in japan research also shows a steady decline in the participation rates in primary and junior high school sports bukatsu extracurricular school club activities 5 6 7 a decline in sports bukatsu participation is particularly concerning as most youth sport and physical activity occurs within japans public education system with bukatsu playing a central role 5 8 9 10 in junior high schools the focus of this study it was estimated in the 1990s that over 90 of students participated in sports bukatsu 1997 cited in 11 recent estimates show a further decrease in participation from 233 million in 2009 to 200 million in 2018 a drop of 131 7 attrition rate estimates over the next few decades are predicting a steady decline in bukatsu participation of around 36 between the baseline year of 2009 and 2048 7 the reason for the decline is twofold first diminishing rates of sports bukatsu participation intersects with broader sociodemographic trends in japan that have seen a reduction in student numbers due to the rapidly declining birth rate this has resulted in an increasing number of school closures and budget cuts to public education causing the remaining schools to reduce the variety of sports that are available or even abolish sport bukatsu activities in the public education system 10 second traditional sporting bukatsu activitiesmartial arts baseball athletics rugby and volleyballare commonly characterized by strict social hierarches between senpai senior students and kohai junior students and ideologies of perseverance and selfsacrifice developed through long hours of practice and a competitive disposition 10 the aim of this approach is to develop the spirit and sense of self of students through hard work within a group setting 10 consequently bukatsu have tended to center around a small number of highly dedicated and elite student athletes which research shows acts as a deterrent for wider participation in contemporary school sports 10 outside japan the english literature suggests that incorporating lifestyle sports into public education curricula may better align with current youth trends and help to address some of the challenges noted above 12 13 14 15 however empirical research on how lifestyle sports are being integrated into a diverse range of public education systems outside western contexts has yet to be fully explored drawing on the example of aoshima junior high schools surfing bukatsu the purpose of this article is to offer contextual insights into how the lifestyle sport of surfing is being incorporated into the japanese public education system detailing the strategies of change and continuity as surfing expands and transforms within the bukatsu system we ask how do the meanings and experiences of both surfing and bukatsu change when it becomes institutionalized into japans public education system and what significance is given to the surfing bukatsu in relation to the public education student wellbeing and the local communities in which they are embedded to address these questions this article begins by contextualizing the historical evolution of and current issues facing sports bukatsu activities in japan we then examine the literature investigating the role of lifestyle sports in public education systems outside japan next the research context of aoshima junior high school is outlined and the ethnographic methodology is explained the findings are then organized into three thematic discussions new collectivism contest surf style and bukatsu in the community we conclude by outlining the contribution of this study to the emerging scholarship on lifestyle sports and public education and suggest areas for future research in this field specifically for nonwestern contexts literature review 21 bukatsu a brief history and current issues the relationship between sport and public education in japan can be traced back to the edo era with a focus on fostering samurai philosophy and principles through martial arts bushido the purpose of physical education was to purify the mind develop the spirit and instill a sense of stoic discipline 516 taught within private schools affiliated with regional clans or families sporting practice emphasized control of ones mind over technique and the development of yamatodamashii a discourse commonly employed to describe an indigenous japanese spirit 17 the priority given to developing a national spirit through sport continued when imported western sports like baseball rugby football tennis and volleyball were introduced during the meiji restoration sporting educ sci 2023 13 1111 3 of 24 institutions positioned western sports as a fusion of the values of samurai culture with victorian values of manliness in the practice of team games during early meiji sports bukatsu became one of the main social institutions for seishin kyoiku meaning education of the spirit 5 the formation of the sports bukatsu system known today began within tokyos university school system where western sports were institutionalized and later spread throughout the country 5689 the integration of sports into the public education system was furthered when western sport bukatsu were incorporated into high school curriculums and later into junior high schools during the showa era japan plunged into war public resources were directed towards war efforts referred to as the total war system including those directed towards sports bukatsu which were also adapted to support war activities 89 sports bukatsu transformed into a form of auxiliary military training which nakazawa refers to as organized national defense training clubs 9 this infused military values of masculinity discipline perseverance respect for hierarchy and group solidarity into sports bukatsu culture 91920 following the war many bukatsu activities came to an abrupt halt as there was no longer time or money to support these club activities 9 history shows that bukatsu are flexible and served different agendas of the times 5 following the war bukatsu once again transformed to support a new national vision promoting a democracybased educational reform 920 instead of teachers giving orders and students simply following them bukatsu were repurposed to encourage student independence and the enjoyment of sport in an attempt to make sports bukatsu activities more accessible and attractive to a diverse range of students 9 however uchiumi 19 argues that even during this democratic era prewar feudalistic principles wartime nationalistic values and a continued focus on development of the japanese spirit persisted although more inclusive postwar sports bukatsu remained a site where nationalist values could be maintained within a modernizing public education system and a globalizing japan 19 negotiating this tension between tradition and change contemporary research on bukatsu and public education focuses on three prevailing themes first research has examined the entrenched cultural practice of the senpaikohai relationship which establishes a strict social hierarchy by emphasizing respect for seniority following a chain of command and group unity over individual outcomes 2122 research shows that the senpaikohai relationship can foster respect cooperation and social bonds between seniors and juniors in an environment more closely resembling the social reality they will experience as working adults thereby shaping the beliefs and values of youth to align with broader societal norms 2223 however these studies also discuss how a strict social hierarchy and a principle of winning at all costs shori shijoshugi makes the sports bukatsu experience uncomfortable for many students acting as a deterrent for broader student engagement it is also unfortunately common to see news reports of harassment bullying and even student suicides caused by problems related to senpaikohai relationships in bukatsu activities 24 a second related area of research concerns the effects of bukatsu on students mental and physical health research shows how a competitive ideology and the spiritual development approach to bukatsu creates an environment where excessively long hours of practice corporal punishment taibatsu by coaches and physical abuses at the hands of the senpai are normalized 1011 25 26 27 28 omis 11 survey of university students found that 25 of respondents had been physically punished during their school days which took place mostly in a bukatsu setting of course research shows that student participation in bukatsu activities can also have a positive impact on academic performance and motivation 2729 however in terms of the impact on students mental and physical health research suggests the way that sports bukatsu has historically developed has led to some notable negative impacts on youth psychological development 2730 and has become a major social issue that remains under debate 28 a third area of study has started to focus on bukatsus relationship or lack thereof with local communities 103132 sugimoto et al 32 for instance argue that collaboration with local sports bukatsu and nontraditional sports outside of the school grounds could be one strategy for responding to the diverse sporting aspirations of todays students and lack of school resources 32 others suggest that there is a need for a more flexible bukastu system making it easier for students to participate in wide range of sporting activities by improving their relationships with external coaching systems and allowing multiple schools to collaborate when necessary 10 improving the relationships between bukatsu and local stakeholders could be a useful strategy reconnecting bukatsu with local communities and helping to foster lifelong sports engagement in japan 10 this raises some interesting and timely questions that are relevant to this study how might lifestyle sports like surfing be incorporated into this complex bukatsu history and are lifestyle sports better positioned to align with a communitybased approach to japans bukatsu system thereby addressing the concerns identified in the previous literature lifestyle sports and public eductaion in contrast to japans sports bukatsu activities lifestyle sports are commonly characterized as informal individual and inclusive pursuits with a focus on personal enjoyment the development of technical prowess and individual selfimprovement 1233 lifestyle sports emerged out of the 1960s alternative and countercultural surfing scene in california but today comprise a wide range of activities including ocean sports like standup paddle boarding foiling windsurfing and kitesurfing and land sports such as skateboarding snowboarding parkour freestyle bmx bouldering and rock climbing 3334 global participation in lifestyle sports has rapidly increased over the past three decades 123536 and with their inclusion in the tokyo 2020 olympic games further institutionalization and expansion into new markets are anticipated 12 as a result lifestyle sports have become increasingly embedded into national sports systems 1 local public policy and governmental regulation 37 university club activities 38 and increasingly into public physical education programs 121439 the primary argument for incorporating lifestyle sports into public education is that these activities have the potential to encourage greater participation in sports and physical activity among those who are not actively involved or interested in mainstream school sports 131435 lifestyle sports differ from mainstream sports in that they are argued to be inclusive anticompetitive less rulebased have a collegial attitude and focus on the selfexpressiveness of the individual 121435 lifestyle sports have increasingly gained acceptance in recent years because they do not place as much pressure on the individual to win resulting in more positive psychological outcomes 40 and meaningful experiences that promote ongoing engagement and lifelong learning opportunities 4142 at a time when the level of physical activity among youth is declining the inclusion of lifestyle sports in pe curriculums is one possible way to increase physical activity among youth worldwide 1213 the inclusion of lifestyle sports in public education around the world has emerged at different times and out of differing social political and economic contexts for example in australia surfing played an important role in liberal education reforms as far back as the 1960s which sought to encourage youth selfexpression and selfrealization 43 this liberal education model would eventually transform into a more professionalized and institutionalized educational practice with surfing today continuing to play an important part of the school pe curriculum at all levels including at the national policy level 33 and within the national psyche 43 in the context of the uk attention has largely focused on addressing the aforementioned issues of youth obesity and low levels of physical activity with research exploring lifestyle sports from a pedagogical perspective 12 investigating the uk governments efforts to promote greater participation in sport and physical activity among youth 13 and examining the physical mental and social benefits of incorporating lifestyle sports into the pe curriculum 121435 leeder and beaumonts 14 study further examines complexities that pe teachers encounter when implementing lifestyle sports identifying several challenges to the implementation of these activities within the school curriculum including logistical issues like lack of time skills and qualifications funding and access to resources and facilities king and church 13 identified another important benefit of lifestyle sports for pe curricula which is that they take place in natural and outdoor settings which has important implications for achieving the uk governments goal of encouraging young people to make healthy longterm lifestyle choices lifestyle sport research in east asia and japan has only recently started to gain attention 334 44 45 46 and to date investigations into the relationship between lifestyle sports and public education in japan are rare there are only a few sporadic examples where schools in japan have adopted lifestyle sports as a bukatsu activity or have established them as a part of departmental courses iwaki kaisei high school in fukushima prefecture incorporated marine leisure and marine sportsincluding surfinginto its educational content in the 1990s to attract students to the school by promoting the unique coastal resources of the area 47 daiichi gakuin high school a correspondencecredit high school with schools in ibaraki and hyogo established a skateboard bukatsu in conjunction with the japan skateboarding federation with a competitive focus students train to become top athletes under instructors who are professional skateboarders recruited by the school to assist with the lifestyle sports pe curriculum 48 other examples include the japan surfing academy high school 49 with schools in kanagawa and chiba prefectures and the shonan surfing academy 50 located in kanagawa prefecture where students can earn a high school diploma with a focus on surfing training them to become professional surfers surf coaches judges and surf industry professionals other recent examples include meisei high school and kamogawa reitoku high school both correspondence schools in chiba prefecture which have established surfing bukatsu 5152 shizuoka prefectural sagara high school and shimoda municipal shinshimoda junior high school in shizuoka prefecture also have plans to establish surfing bukatsu as a club activity in the near future 53 some important preliminary insights can be drawn from the examples above first the incorporation of lifestyle sports into the public education system has a strong focus on the professional development of surfers competitive surfing and contributing to the surf industry second lifestyle sports bukatsu have previously been and are currently being positioned as a promotional niche for schools to differentiate themselves in the privatized educational marketplace lifestyle sports are providing schools with a modern and unique identity fulfilling hopes of attracting more students at a time when the educational system is suffering from student depopulation especially in rural regions of japan we see an emerging trend of lifestyle sports gradually becoming incorporated into the educational system in japan but there is no research examining the meanings and experiences of those involved with these new forms of lifestyle sports bukatsu research context and methodology aoshima junior high school a rural school in japans surfing mecca aoshima junior high school is located in miyazaki prefecture of southeastern kyushu along japans pacific coast it is a small fishing village located 20 km south of miyazaki city and like many rural communities throughout japan is facing significant challenges associated with rapid population decline an aging community and a struggling economy 5455 statistical data since 2000 indicate that the population decline is accelerating the rapid economic development of urban centers during the economic boom in the 1980s led to the depopulation of rural japan causing peripheral communities like aoshima to bear a disproportionate burden of postindustrialization rapid economic development of urban centers during the economic boom in the 1980s led to the depopulation of rural japan causing peripheral communities like aoshima to bear a disproportionate burden of postindustrialization aoshima was not always this way during the 1960s and 1970s aoshima was renowned for being the most popular honeymoon resort destination in japan in 1974 a total of 370000 newly married couples visited aoshima representing almost onethird of all married couples in the nation 56 however as international travel become more affordable leading into japans economic boom during the 1980s tourism and economic development in the region were sent into a rapid decline the three decades that would follow came to be referred to as the lost decades ushinawareta junen 57 however in the 1990s a new resource for rural revitalization began to emerge in other areas of miyazaki surfing 54 in 1993 the sheraton seagaia resort was opened 40 km north of aoshima the mega resort included the seagaia ocean dome which at the time was the worlds largest indoor surfing wave pool between 1991 and 1993 miyazaki prefecture would collaborate with the association of surfing professionals world tour now called the world surf league to host the miyazaki pro international surf contest bringing all of the worlds best surfers to the area miyazaki came to be referred to as japans surfing mecca 54 and although many of these new investments were not directly in aoshima the economic and social value of surfing and surf culture was gaining recognition throughout the region miyazaki including the emerging leisure beach culture of aoshima is now recognized as being amongst the most popular surf towns in japan miyazakis rich surfing history played an integral role in the establishment of aoshima junior highs surfing bukatsu the turning point was when the 2019 international surfing association world surfing games were held at kisakihama beach in miyazaki from 715 september 58 the isa world surfing games contributed towards qualification for the surfing event in the 2020 tokyo olympic games and included 240 participants from 55 countries in preliminary interviews with the school administration it was explained that as the event was connected to the olympics it garnered greater attention from the public than previous surfing events as a result the 2020 tokyo olympics and the 2019 isa world surfing games helped the sport of surfing become more widely accepted in this small rural community aoshima was not always this way during the 1960s and 1970s aoshima was renowned for being the most popular honeymoon resort destination in japan in 1974 a total of 370000 newly married couples visited aoshima representing almost onethird of all married couples in the nation 56 however as international travel become more affordable leading into japans economic boom during the 1980s tourism and economic development in the region were sent into a rapid decline the three decades that would follow came to be referred to as the lost decades ushinawareta junen 57 however in the 1990s a new resource for rural revitalization began to emerge in other areas of miyazaki surfing 54 in 1993 the sheraton seagaia resort was opened 40 km north of aoshima the mega resort included the seagaia ocean dome which at the time was the worlds largest indoor surfing wave pool between 1991 and 1993 miyazaki prefecture would collaborate with the association of surfing professionals world tour now called the world surf league to host the miyazaki pro international surf contest bringing all of the worlds best surfers to the area miyazaki came to be referred to as japans surfing mecca 54 and although many of these new investments were not directly in aoshima the economic and social value of surfing and surf culture was gaining recognition throughout the region miyazaki including the emerging leisure beach culture of aoshima is now recognized as being amongst the most popular surf towns in japan miyazakis rich surfing history played an integral role in the establishment of aoshima junior highs surfing bukatsu the turning point was when the 2019 international surfing association world surfing games were held at kisakihama beach in miyazaki from 715 september 58 the isa world surfing games contributed towards qualification for the surfing event in the 2020 tokyo olympic games and included 240 participants from 55 countries in preliminary interviews with the school administration it was explained that as the event was connected to the olympics it garnered greater attention from the public than previous surfing events as a result the 2020 tokyo olympics and the 2019 isa world surfing games helped the sport of surfing become more widely accepted in this small rural community according to the school principal students were relocating to other schools to join other bukatsu activities like basketball at the time of this study in 2021 the student population of aoshima junior high school was extremely low comprising a total of 51 students 10 third grade students 17 in the second grade and 24 in the first grade it was decided that the school needed to establish a bukatsu that could embody the uniqueness of the local community be the pride of the school prevent the declining number of students and help revitalize the surrounding community shortly after the isa world surfing games a school survey was conducted amongst the parents and community members to decide which new sport bukatsu could help attract new students to the school over 80 of the student and parent respondents replied surfing and in april 2020 one of japans first public junior high school surf bukatsu was established 59 ethnographhic fieldwork leeder and beaumont 14 suggest that future research on the emerging field of lifestyle sports and public education could benefit from engaging with ethnographic methodologies in a diverse range of contexts to incorporate the multiple voices and perspectives of the stakeholders that are involved evers and doering 34 further argue for more targeted contextspecific ethnographic insights into the incorporation of lifestyle sports throughout east asia which is a diverse region with its own unique histories interests needs desires and perspectives this article takes up this call by employing an interpretivist ethnographic approach to offer empirically rich and grounded details regarding the meanings experiences and tensions of a diverse range of stakeholders involved in surfing bukatsu activities an ethnographically inspired approach places emphasis on the importance of cultural and sitespecific understandings with respect to the challenges and cultural specificities of incorporating lifestyle sports into the public education systems in nonwestern contexts fieldwork was conducted over a period of ten days from 18 july 2021 to 27 july 2021 with some preliminary interviews with administrative staff being conducted in september 2020 although brief as wheaton 1 argues even short ethnographic visits can provide important insights into the study of lifestyle sports ethnographic material was gathered through participant observation indepth interviews and focus groups both at the school and on the beach the fieldwork was carried out during the students summer holidays and of the ten days six were spent practicing in the sea one day was spent trainingstudying at school and then going to the beach to practice and for three days there was no practice on practice days on the sea some parents would join the students as supervisors in the water while others watched from the beach some of the interviews with the parents took place at this time the interviews with the students and their advisors were conducted at the school rather than at aoshima beach at the time of the study the surfing according to the school principal students were relocating to other schools to join other bukatsu activities like basketball at the time of this study in 2021 the student population of aoshima junior high school was extremely low comprising a total of 51 students 10 third grade students 17 in the second grade and 24 in the first grade it was decided that the school needed to establish a bukatsu that could embody the uniqueness of the local community be the pride of the school prevent the declining number of students and help revitalize the surrounding community shortly after the isa world surfing games a school survey was conducted amongst the parents and community members to decide which new sport bukatsu could help attract new students to the school over 80 of the student and parent respondents replied surfing and in april 2020 one of japans first public junior high school surf bukatsu was established 59 ethnographhic fieldwork leeder and beaumont 14 suggest that future research on the emerging field of lifestyle sports and public education could benefit from engaging with ethnographic methodologies in a diverse range of contexts to incorporate the multiple voices and perspectives of the stakeholders that are involved evers and doering 34 further argue for more targeted contextspecific ethnographic insights into the incorporation of lifestyle sports throughout east asia which is a diverse region with its own unique histories interests needs desires and perspectives this article takes up this call by employing an interpretivist ethnographic approach to offer empirically rich and grounded details regarding the meanings experiences and tensions of a diverse range of stakeholders involved in surfing bukatsu activities an ethnographically inspired approach places emphasis on the importance of cultural and sitespecific understandings with respect to the challenges and cultural specificities of incorporating lifestyle sports into the public education systems in nonwestern contexts fieldwork was conducted over a period of ten days from 18 july 2021 to 27 july 2021 with some preliminary interviews with administrative staff being conducted in september 2020 although brief as wheaton 1 argues even short ethnographic visits can provide important insights into the study of lifestyle sports ethnographic material was gathered through participant observation indepth interviews and focus groups both at the school and on the beach the fieldwork was carried out during the students summer holidays and of the ten days six were spent practicing in the sea one day was spent trainingstudying at school and then going to the beach to practice and for three days there was no practice on practice days on the sea some parents would join the students as supervisors in the water while others watched from the beach some of the interviews with the parents took place at this time the interviews with the students and their advisors were conducted at the school rather than at aoshima beach at the time of the study the surfing bukatsu comprised 20 students 10 second year students and 10 first year students ethnographic fieldwork was conducted during the summer holidays and 11 students were present at the time of this study the fact that several students were absent from the surfing bukatsu activities throughout the week demonstrates the informality and flexibility of the club a key finding discussed later in our findings in the japanese context school summer holidays still means going to school every day for practice to prepare for summer competitions even during the peak of summer holidays it is common to see students riding their bikes in the early morning on their way to practice all across japan voluntary absence from practice typically means one cannot join in the competition games we asked about the absence of some of the students during the week and were told by some that this was because of the flexibility of the surfing bukatsu some students involved in activities outside of the school or in collaboration with clubs in other schools were prioritizing those activities and were allowed to combine these activities the absence of students does not mean that they were dissatisfied with the surfing bukatsu but appreciated the flexibility to combine surfing bukatsu with other sporting activities therefore although the limited percentage of student participants is a limitation of the study it is also demonstrative of the flexibility and informality of the surfing bukatsu which is extremely rare in the traditional bukatsu system a total of 22 people involved in the surfing bukatsu at aoshima junior high school were interviewed this included a wide range of participants including students parents principals advisors external coaches sponsors and residents all participants helped inform the interpretation of the study but in different ways as the focus of the research was on understanding the meanings and experiences of participants directly involved in the daily activities of the surfing bukatsu emphasis and voice was given to students parents coaches and teaching staff experiences the purpose of interviews with participants who were lessdirectly involved in the daily operations being represented in the findings was twofold first these participants are gatekeepers in the community note that these are presidents and owners of large hotels and members of indirectly related government agencies nevertheless respect for hierarchy is paramount for conducting research in japan and entering any field commonly requires talking with influential community members it was recommended that we talk to these participants to understand their role in helping to start the surfing bukatsu secondly this information was helpful for understanding the context and background of the early emergence of the surfing bukatsu but could not offer detailed insights into the current experiences and meanings as understood by those directly involved in the daily practice the interviews lasted between 10 and 90 min with five interviews using a voice recorder and the other 17 being documented in fieldwork notebooks as the focus of this study is on sports bukatsu and the participants interactions as a group it was decided that a focus group discussion with the surfing bukatsu students could provide additional insights into the social group dynamics the focus group took place during the 9th day of fieldwork with 11 students and was conducted in the classroom with students sitting in a circle at their own desks the focus group was conducted independently by the first author a young japanese female university student and in the japanese language to create a comfortable environment and make it easier for the groups collective feelings to emerge 6061 the focus group lasted 90 min the focus group and formal interviews with parents teachers and coaches were semistructured centering on participants meanings and experiences of surfing and bukatsu activities before and after joining the club previous experiences with bukatsus social hierarchies and current experiences with the surfing bukatsu surfing competitions the flexibility of the surfing bukatsu organization and aoshima as a place to live and grow up written informed consent was obtained from all participants involved in the study the recorded interviews were transcribed and all of the fieldwork notes were converted into electronic data all interviews were conducted in japanese and translations of the material were made by the authors the aim of our analysis was to develop an understanding of how the surfing bukatsu was experienced by multiple stakeholders and its meanings for the participants and the community the process was hermeneutic inductive and emergent with the two authors working in collaboration to cointerpret and cotheorize the surfing bukatsu experience via the ethnographic text continually discussing and reexamining the data from the field at all stages of the fieldwork process the ethnographic material was then read and reread alongside previous research with the emergent themes confirmed with the adult participants of the study through email and messaging the final analysis aimed to bring to life the subtle sociocultural changes and tensions as explained by the participants and interpreted by the researchers three prevailing themes emerged from the analysis that form the basis of our ethnographic interpretation of aoshima junior high schools surfing bukatsu new collectivism contest surf style and bukatsu in the community new collectivism reimagining social hierarchy in aoshimas surfing bukastu the western literature argues that one of the most important characteristics of lifestyle sports pedagogy is that they are noncompetitive and allow for the individual to gain a sense of achievement without competing with other teams or players 12153335 this sense of noncompetitiveness is the reason that some argue lifestyle sports can be more inclusive for a diverse range of student interests in contrast the collectivism of traditional bukatsu activities in japanese public education is seen as an important tool for socialization in a society where often the group takes precedence over the individual 1162 from the perspective of public education providers the importance of buskatsu activities is in fostering a social and collective group dynamic according to the japan sports agencys 63 definition in the courses of study guidelines the purpose of bukatsu is cultivating a sense of solidarity to develop students skills and capabilities within the group life of public education and broader society omi 11 describes this approach to bukatsu as a form of downward collectivism characterized by the suppression of individual expression and individuality a tension between these two competing discourses of lifestyle sports and bukatsu was at play in the early development of the surfing bukatsu but following a difficult first year a new collectivism started to emerge where the individuality flexibility and informal comradery that characterize lifestyle sports became incorporated into the collective social hierarchies that have long defined traditional bukatsu individual and group tensions in lifestyle sport bukatsu activities the tension between the ideal of surfing as an individual sport and the collective mentality of traditional bukatsu was described in many conversations and interviews when asked about surfing parents often emphasized the value of surfings individuality with one parent declaring that surfing is an individual sport and another describing it as quite a solitary sport the surfing bukatsu teacher advisor further reinforced the contrast between surfing and bukatsu activities explaining that surfing is originally an individual sport so there is a big gap with bukatsu activities he continued to explain that by incorporating surfing into the bukatsu system the original meaning of surfing as a free individual and creative expression was cut in half it was clear that parents advisors and teaching staff perceived surfing as an individual pursuit that was not common to traditional bukatsu culture this tension surfaced early in the development of the surfing bukatsu during the clubs first year in 2020 teachers students and parents alike considered surfing as an individual sport but noted that the public education system is designed to place more emphasis on the collective group dynamic where as the former principal described all members practice the same thing at the same time and place this meant that surfing practice mostly took place in the school swimming pool during the first year where unlike the unpredictable and dangerous ocean group activities could be scheduled in advance and completed as a group the first school principal who helped found the bukatsu further explained that surfing is like any other sport bukatsutennis swimming baseballand even though it is called a surfing bukatsu it is still a bukatsu activity so we want the students to learn mana good manners and reigi etiquette from this perspective surfing bukastu was still a public educational activity and as a public official the goal was to maintain the traditional values of bukatsu activities in the new surfing context in interviews with teacher advisors coaches teaching staff and parents we learned that parents of the more advanced surfers began to question the traditional grouporientation of bukatsu activities weekday surfing practice in the pool was not improving anyones skills tensions began to arise between parents who saw surfing as a more individual pursuit with a focus on selfexpression and personal improvement and public officials seeking to maintain the grouporiented nature of bukatsu the traditional group orientation of bukatsu activities was not aligning well with this new lifestyle sports bukatsu this tension was eased in 2021 the bukatsus second year with the appointment of a new school principal changes in school leadership had a profound impact on the management and social environment of bukatsu activities parents and advisors explained that with new leadership the bukatsu changed to a more flexible form of bukatsu activities for example under supervision of their parents more advancedlevel students were allowed to be absent from the group practice days when the waves were better at the other surf breaks in southern miyazaki this created a more flexible environment with parents taking on an important supervisory role in the bukatsu activities this also allowed the surfing bukatsu to better accommodate the differing skill levels and interests of individual students this developed into what we refer to as a new collectivism where a strong sense of group belonging remained while also catering to these individual needs during the focus group the advanced surfing students explained that they did not only want to surf alone as its more fun and exciting to surf together this was echoed in the focus group with the beginnerlevel students explaining that they support the individual efforts of the more advanced students individual practice based on skill level was seen as a benefit to the group we want the good kids to keep going to the good surf points to practice we want to see them improve too despite catering to individual skill levels and training requirements a strong sense of group identity and sense of belonging was clear this marked the beginning of a new collectivism one where the bukatsu is transformed into a more flexible horizontal organizational culture that includes parent supervision and accommodates for individual needs while still maintaining a sense of social group cohesion but as we will now explore in nonhierarchal ways social environment of bukatsu activities parents and advisors explained that with new leadership the bukatsu changed to a more flexible form of bukatsu activities for example under supervision of their parents more advancedlevel students were allowed to be absent from the group practice days when the waves were better at the other surf breaks in southern miyazaki this created a more flexible environment with parents taking on an important supervisory role in the bukatsu activities this also allowed the surfing bukatsu to better accommodate the differing skill levels and interests of individual students this developed into what we refer to as a new collectivism where a strong sense of group belonging remained while also catering to these individual needs during the focus group the advanced surfing students explained that they did not only want to surf alone as its more fun and exciting to surf together this was echoed in the focus group with the beginnerlevel students explaining that they support the individual efforts of the more advanced students individual practice based on skill level was seen as a benefit to the group we want the good kids to keep going to the good surf points to practice we want to see them improve too despite catering to individual skill levels and training requirements a strong sense of group identity and sense of belonging was clear this marked the beginning of a new collectivism one where the bukatsu is transformed into a more flexible horizontal organizational culture that includes parent supervision and accommodates for individual needs while still maintaining a sense of social group cohesion but as we will now explore in nonhierarchal ways theres no need for hierarchy reimagining senpaikohai relations group cohesion in traditional sports bukatsu is commonly defined by a strict social hierarchy this topdown hierarchical structure of sports bukatsu has been discussed in many studies and news reports about the japanese public education system 222445 it is argued that the hierarchical relationship between senpai senior students and kohai junior students in sports bukatsu activities fosters a domineering and unequal power relationship 64 what omi 11 refers to as a downward collectivism that can repress individual expression a concern for this traditional bukatsu social hierarchy was expressed by several parents when asked about their own experiences of bukatsu activities one parent theres no need for hierarchy reimagining senpaikohai relations group cohesion in traditional sports bukatsu is commonly defined by a strict social hierarchy this topdown hierarchical structure of sports bukatsu has been discussed in many studies and news reports about the japanese public education system 222445 it is argued that the hierarchical relationship between senpai senior students and kohai junior students in sports bukatsu activities fosters a domineering and unequal power relationship 64 what omi 11 refers to as a downward collectivism that can repress individual expression a concern for this traditional bukatsu social hierarchy was expressed by several parents when asked about their own experiences of bukatsu activities one parent noted in our day bukatsu was all about senpai and kohai relationships we had to say hello to the seniors when they passed by we were afraid of them if we didnt greet them properly we were more concerned about our senpai than our teachers as another parent put it i really didnt like the military aspect of the bukatsu activities parents expressed that they did not want the same experience for their children and the surfing bukatsu was understood as a possibility to establish new forms of social relations for their children with a new collectivism forming different kinds of social relations began to emerge when the surfing bukatsu was founded there were three thirdyear students and nine firstyear students a total of 12 members at that time none of the thirdyear students had surfing experience however they each had experience in mainstream sports and knew the hierarchal structure of traditional bukatsu initially the teacher advisor also believed that bukatsu activities were a place to learn about hierarchical relationships and so he instructed the students with this in mind however this mode of social hierarchy did not make much sense in the surfing bukatsu as the thirdyear students who had never surfed before were supposed to be guiding the firstyear students who were the more experienced surfers this made the teacher advisor rethink this approach i now dont put too much emphasis on this traditional senpaikohai relationship were not going to put too much emphasis on hierarchy because the times are changing when students were asked during the focus groups about the bukatsu social hierarchy responses included there is no seniority there is no hierarchy there is peace if there was hierarchy the atmosphere would be bad it wouldnt be fun as one second grade student described there is no need for hierarchy you dont have to stress about other people senpai and kohai like in other bukatsu it was clear that the current members of the surfing bukatsu felt that there was no need for this traditional sense of bukatsu social hierarchy a sentiment echoed by the one parent who commented in the surfing bukatsu its not so much about seniority but more about the kids who are good teaching the kids who are not so good from what ive seen everyone is pretty relaxed we used to say hi to our seniors at school because we were afraid them now students admire and respect each other because of their skill i often hear my son express his admiration for the younger surfers at home saying things like xxkun is good the reimagining of social relations within the surfing bukatsu was informed in part by the skill level difference between the members the change in school principal and the teacher advisors change in attitude by the second year it became clear that a new collectivism had formed characterized by the sharing of opinions and skills collegiality and cooperation amongst students regardless of their grade level the organizational structure became more flexible more supportive of individual needs and fostered a sense of group belonging based on mutual respect and support for each others skills rather than seniority participants described the surfing bukatsu as being more inclusive democratic and welcoming than both the parents and students previous experiences of traditional bukatsu contest surf style negotiating competitive and informal benefits incorporating lifestyle sports into traditional bukatsu public education allows for new possibilities and practices of individualization and flexibility but this focus on individual skill development may also incidentally maintain the priority given to competition found in traditional bukatsu otake and ueda 10 argue that sports bukatsu activities have a long history of being competitive sports between schools to the extent that it is generally assumed that sports bukatsu activities are synonymous with competition the benefits of selfdevelopment and fostering group cohesion and school pride are said to derive from this competitionbased approach in contrast english research suggests that the benefits and opportunities associated with incorporating lifestyle sports into public education come from their noncompetitive informal and inclusive structure 12133536 debates concerning the intrinsic and external value of competition also form the foundation of the philosophy of sport examining the pursuit of victory or the pursuit of excellence as a desirable aim or outcome of sporting competition 6566 the philosophy of sport therefore asks us to reflect on the meanings of sport itself however the constructivist paradigm taken up in this study takes a pluralist approach to meaningmaking understanding that sport culture is emergent rather than fixed with meanings being negotiated from the sociocultural and historical situatedness of a given sport in a particular context 67 what follows is an analysis of the meaningmaking of competition as the lifestyle sport of surfing intersects with the history and social setting of competition within the bukatsu experience in the interviews an importance placed on establishing surfing bukatsu competitions was apparent with several of the study participants placing a strong emphasis on building the junior high school surfing competitions into a national competition this raises a concern that placing too much emphasis on surfing bukatsu competitions may in the longterm undermine the benefits attributed to lifestyle sports which have been identified in previous literature the aim here is not to judge whether surfing competition is good or bad rather the purpose of discussing the emergence of a contest surf style is to contextualize the historical role of competition in sports bukatsu identify how competition is currently being discussed in the surfing bukatsu and to contrast this with the student wellbeing benefits as pointed out in the literature and described by some participants themselves winning at all costs shori shijoshugi bukatsu and the growth of competitive surfing the competitive ideology of winning at all costs shori shijoshugi has been an important point of debate in the literature on sports bukatsu activities attracting attention not only in academic circles 10192227 but also in the mass media early research in the field by imahashi et al 71 points out that the competitive nature of bukatsu activities has led to injuries as well as overall health and wellbeing concerns among students as tomozoe 20 argues some schools even prioritize bukatsu activities over schoolwork and until the 1960s strict standards had to be set for interschool competitions to help manage this winning at all costs attitude however due to the declining birth rate in recent years there has been a shifting trend towards coopting bukatsu activities and success in competitions as a promotional tool demonstrating the attractiveness of a given school in an increasingly competitive educational marketplace 2022 in this way bukatsu continues to play an important role in school promotion and attracting students but the winningatallcosts attitude still casts a shadow over the bukatsu system 2022 our interviews reveal that the surfing bukatsu at aoshima junior high school also seeks to maintain this competitive bukatsu framework although currently in a much less serious manner than the conventional winningatallcosts approach on 1011 october 2020 the first all miyazaki junior high school surfing competition aoshima cup 2020 was held hosted and organized by the aoshima junior high school surfing bukatsu the competition was open to all junior high school students in miyazaki prefecture and attracted a total of 28 participants thirteen competitors were from outside of aoshima junior high school as the fieldwork took place at the end of september there was a buzz in the air about the upcoming competition teaching advisors surf coaches parents and the school principal each explained how they considered competition to be an important tool to keep students motivated and challenging themselves through bukatsu activities as the father of one of the advancedlevel students described it i think the surfing competition has given the kids a lot of motivation this was echoed by the teacher advisor who commented i felt it was important to have a tournament or a place where everyone can see how much they have improved and show their achievements the external advisor and surf coach outlined the future goals of the surf club stating we want to hold more competitions i want to give the students the experience of winning as a team on the day of the competition we wrote to see how the event was going with one father responding everyone is buzzing about it hopefully itll grow and get bigger every year the waves were actually pretty good for the contest and offered something for all the different levels it was on the local mrt news last night i think the kids all enjoyed themselves the discourse of a need to develop and expand the competitive aspects of the surfing bukatsu reminded us of the first interview with the former principal a year earlier the former principal explained that surfing is not a mainstream sport in japan and that if they hoped to make the surfing bukatsu a success they needed to figure out what competition was needed to make it a major sport in japan according to the principal the final goal would culminate in establishing an alljapan surf competition in collaboration with the nippon surfing association the aoshima cup is one small step towards a larger path of increasing the professionalization and institutionalization of the sport as anticipated by the former principal in the short term the findings show that both parents and coaches saw the competitive aspects of surfing as important for keeping students motivated throughout their bukatsu activities in the long run however one can also understand this process as a slow movement towards an increasing focus on competition which could possibly lead towards the competitive disposition that has characterized more traditional approaches to bukatsu 72 as the fieldwork took place at the end of september there was a buzz in the air about the upcoming competition teaching advisors surf coaches parents and the school principal each explained how they considered competition to be an important tool to keep students motivated and challenging themselves through bukatsu activities as the father of one of the advancedlevel students described it i think the surfing competition has given the kids a lot of motivation this was echoed by the teacher advisor who commented i felt it was important to have a tournament or a place where everyone can see how much they have improved and show their achievements the external advisor and surf coach outlined the future goals of the surf club stating we want to hold more competitions i want to give the students the experience of winning as a team on the day of the competition we wrote to see how the event was going with one father responding everyone is buzzing about it hopefully itll grow and get bigger every year the waves 52 creating a space to be at ease maintaining the benefits of an informal surf bukatsu tomozoe 20 argues that the benefits of bukatsu activities should not only focus on competition as bukatsu also represents a significant space where students can feel at ease in the world and societyreferred to as ibasho meaning a place where one can be at ease in the interviews the teacher advisor komon explained how this sense of beingatease was described by some students in that the surfing bukatsu is a culture not a competition or anything we do it because its fun to ride waves with everyone its good if they can surf with everyone and just have fun this sense of just having fun and beingatease was also described as having a positive effect on the physical and mental health of their children one mother of a firstyear student explained that her childs mental state had improved since joining the surfing bukatsu the sense of freedom from competition and the informal structure of just being with friendsunstructured social interactionis something that many students valued this was nowhere more evident than when we would join the surf practices and witness students smiling laughing and just playing together in the sea the discussion above echoes the sentiments of the emerging literature on the mental physical and social wellbeing benefits of routine engagements with blue spaces including being in the sea and surfing 73 74 75 britton and foley 73 explored the connection between social practices and place in how people experience immersion in natural blue spaces arguing that surfing can open new spaces for people to be different in the water than they are on land a place to beatease with themselves testimonies were described by the teacher advisor who poetically explained even though they are sidewinds in their everyday lives the students become pure children when they enter the ocean another father explained surfing makes him feel alive and stressfree every day there is no crazy teenager type thing no frustration at all in terms of competition one mother said surfing is a sport whose aite partner opponent companion is nature so his mind is getting stronger students described the intrinsic motivation offered by the informal character of the surfing bukatsu with one advancedlevel student explaining surfing heals me it puts me in a good mood even when i am upset surfing refreshes you and motivates you to do more again just having a space and place for students to be at ease was itself an intrinsic motivating factor exceptional stories of the informal benefits of the surfing bukatsu during the covid19 era were also reported one family decided to move to aoshima from outside the prefecture in april 2021 at the elementary school they attended in osaka strict regulations were imposed due to the outbreak of the new coronavirus and children were forbidden to play in nearby parks or with other children they were even reported to the school if they were found gathering the stress of these days led to a gradual decrease in speaking and communication by the child an increase in gray hair and only being able to eat certain foods due to the stress however after moving to aoshima and joining the surfing bukastu the childs stress and symptoms soon stopped the parents said the feeling of liberation for my child in miyazaki is amazing these parents were amongst the most vocal in arguing for maintaining a sense of informality personal expression and flexibility in the bukatsu a sentiment echoed by others in the study but which was at times contradicted by the push towards a more competitionfocused future for the surfing bukatsu surfing bukastu and schoolcommunity revitalization for aoshimas surfing bukatsu to be successful the public education system had to find new and interesting ways to connect with the community in fact engaging with the community was more of a necessity than an option as the surfing bukatsu would not be possible without close community engagement community involvement was central to the formation of the surfing bukatsu which in turn not only helped with the revitalization of the school but also became implicated in the wider rural regional revitalization efforts in this way the multiple and varied institutions and relationships that assembled around the surfing bukatsu led to a coconstitutive dynamic where lifestyle sports lifestyle mobilities and public education systems intersected and reinforced one another in this section 8 we examine the new and emerging connections between the surfing bukatsu the local community businesses and the natural environment to show the necessity of community engagement for the incorporation of lifestyle sports into public education and the social outcomes that this generates within the japanese context community engagement as neccesity to incorporating lifestyle sports into bukatsu during the second year the daily practices moved from the controlled environment of the schools swimming pool to the sea to relocate outside of school boundaries required new engagements and connections with the local community at the time of the study no teaching staff had experience surfing or training in water safety to ensure the safety of surfing bukatsu members and to develop practical skills external advisors and surf coaches familiar with surfing and ocean safety were necessary the organizational structure of the surfing bukatsu was like other sports bukatsu in that it was directed by a teaching advisor komon and deputy advisor subkomon who are employed as educational staff within the school however as the teaching staff had no previous surfing experience all the technical aspects of surfing needed to be taught by the external advisorsurf coach and at times the fathers of students the external advisorsurf coach was from miyazaki city and a qualified lifesaver who worked as a part time lifesaver at the nagisanokoban seaside patrol station the external advisor is a respected bigwave surfer in japan and due to his close engagement with the local communitys beach activities many of the bukatsu participants noted they had admired him even before joining the club for the surfing community in aoshima having the external advisor gain stable and professional employment as a surf instructor within the public education system was considered a significant step towards legitimizing the role of surfers in the broader community no longer perceived by the public as a problematic subculture young surfers are now training as athletes and surfers have become public educators surfing has moved from an alternative periphery to aoshimas community core as the surf coach explained the surfing bukatsu cannot be completed only with in the school or using school resources and that the support of the community and people from outside the school is necessary and has been very strong close engagement with the community was considered a necessity especially from a public education human resource perspective lifestyle sports may find new ways to connect pe curriculums to the community as identified in the previous literature but in this case community involvement was a foundational part of its incorporation positioning surf bukatsu within the mainstream sporting culture and as an important tool of community revitalization in aoshima has created new relationships with a variety of groups businesses were enthusiastically supportive of this effort the aoshima grand hotel located near aoshima beach provided parking shower facilities and shade for the aoshima junior high school surfing club during their practice times in the sea and for competitions there were also donations of surfboards and wetsuits from nearby surf shops solaseed air an airline company based in miyazaki donated surfboards and wetsuits to the club as part of its corporate strategy to support rural revitalization in the region solaseed air offered lessons for students by professional surfers who were sponsored by the company 7677 spiritual reconnection was also encouraged when nojima shrine located near the school gifted omamori amulets made at the shrine to pray for the students safety at sea the presence of the surfing bukatsu acted as a hub for different kinds of community members to come together public education business local shops and shrines gathering in support of the students students found themselves connected to their community school and the sea in new and interesting ways as the advisor put it the surf club is made up of people from the community it is not like a traditional bukatsu activity because it cannot be completed within the school organization only using the school resources lifestyle sports are considered difficult to incorporate within the school curriculum but from this broader community perspective lifestyle sports can strengthen ties with a wide variety of members from the community suits to the club as part of its corporate strategy to support rural revitalization in the region solaseed air offered lessons for students by professional surfers who were sponsored by the company 7677 spiritual reconnection was also encouraged when nojima shrine located near the school gifted omamori amulets made at the shrine to pray for the students safety at sea the presence of the surfing bukatsu acted as a hub for different kinds of community members to come together public education business local shops and shrines gathering in support of the students students found themselves connected to their community school and the sea in new and interesting ways as the advisor put it the surf club is made up of people from the community it is not like a traditional bukatsu activity because it cannot be completed within the school organization only using the school resources lifestyle sports are considered difficult to incorporate within the school curriculum but from this broader community perspective lifestyle sports can strengthen ties with a wide variety of members from the community school and community building bukatsu lifestyle migration and place attachment during the first interview with the principal of the school in 2020 a new phrase was introduced that has been underrecognised in the lifestyle sport context gakko tzukuri roughly translated as school revitalization the phrase derives from the more common term machi tzukuri which refers to community revitalization and is a key discourse in rural redevelopment in contemporary japan like many rural regions miyazaki city is faced with the challenge of a declining population and has sought to address this issue by offering support for a variety of lifestyle migrants to move to the area 78 school revitalization is considered part of the process of creating a public education system that is more accessible to the local community by working with government officials migration departments families and residents to improve the overall learning environment for childrens development 7 within this context the surfing bukatsu is considered a community club activity with the aim of fostering an attachment to the local environment attracting new migrants to the region and providing more opportunities to deepen cooperation with local businesses and residents news reports suggest that bukatsu activities that make use of local resources have helped halt the declining student numbers 59 likewise the surfing bukatsu was seen as part of this broader community revitalization project revitalizing the school gakko tzukuri was considered an important element of this broader social school and community building bukatsu lifestyle migration and place attachment during the first interview with the principal of the school in 2020 a new phrase was introduced that has been underrecognised in the lifestyle sport context gakko tzukuri roughly translated as school revitalization the phrase derives from the more common term machi tzukuri which refers to community revitalization and is a key discourse in rural redevelopment in contemporary japan like many rural regions miyazaki city is faced with the challenge of a declining population and has sought to address this issue by offering support for a variety of lifestyle migrants to move to the area 78 school revitalization is considered part of the process of creating a public education system that is more accessible to the local community by working with government officials migration departments families and residents to improve the overall learning environment for childrens development 7 within this context the surfing bukatsu is considered a community club activity with the aim of fostering an attachment to the local environment attracting new migrants to the region and providing more opportunities to deepen cooperation with local businesses and residents news reports suggest that bukatsu activities that make use of local resources have helped halt the declining student numbers 59 likewise the surfing bukatsu was seen as part of this broader community revitalization project revitalizing the school gakko tzukuri was considered an important element of this broader social movement with the surfing bukatsu acting as the focal point to attract young families to this rural area we spoke to one family who moved to miyazaki in april 2020 its inaugural year to join the surfing bukatsu at aoshima junior high school they chose to move to aoshima a city they had visited several times on holiday to fulfil their childs wish to be near the sea and join the surfing club his parents noted that before moving to aoshima their child was having difficulties interacting with others but after the move he started to become more outgoing the surfing bukatsu at aoshima junior high school was an important factor in the decision to move already in its first year of existence the bukatsu was attracting young families to the area creating ties between the students and the environment and creating new opportunities to attract new young people to this depopulated rural area recent trends in higher education and employment for high school and university students in miyazaki prefecture in 2018 indicate that although the inprefecture employment rate for high school graduates is gradually improving about half of the 10000 graduates move out of the prefecture for higher education or employment 79 in addition the employment rate for university graduates in the prefecture is only around 40 so there are very few young people who stay in the prefecture or come back to the prefecture we asked about this issue during the focus group with secondyear students discussing what they liked about living in aoshima and how they thought about staying or moving out of the prefecture in the future although one student was considering moving out of the prefecture for higher education the rest of the students said that they would like to have a home to come back to even if they moved away the fact that aoshima junior high school is located about 3 km from the sea easily accessible and always present in their lives was a memorable feature of school life in aoshima as one student simply and powerfully stated the best thing about aoshima is that it is close to the ocean we have always had the habit of playing in the ocean since we were little kids king and church 13 suggest that conducting lifestyle sports in rural naturerich spaces may further enhance the bonds of participants with their place this was evident in the study as the students of the surfing bukatsu were familiar with aoshima beach having made it a part of their lives from an early age joining the surfing bukatsu deepened their relationship with the sea through connections with others the relationships and sense of community built around the sea made possible through the surfing bukatsu were a significant part of their experience as one student explained i am happy to go to the sea in aoshima because i can meet so many different people from the local community the students expressed a feeling of being cared for of the community supporting their learning experience and of being an integral part of the community the surfing bukatsu was therefore not only about establishing a relationship with the sea but also about how the sea connects people and consequently connects students to their place several students expressed that even if they must leave aoshima in the future for higher education or job opportunities they still wish to return one day as one student described even if i leave aoshima i want to have a home to come back to ill always come back a statement that was followed by another student who echoed we have aoshima in our hearts discussion lifestyle sports bukatsu and emergent sporting culture in japan in their overview of lifestyle sports for the future of pe curriculums beaumont and warburton 12 suggest that what is needed today is a redesigning of what pe means for students parents teachers schools and society taking more seriously the perspective of young people and how they give new meanings to their pe experiences in the field of lifestyle sports more generally evers and doering 34 argue that as lifestyle sports gain attention and are increasingly institutionalized throughout east asia it is also important to pay attention to the specific cultural politics unique contexts and histories differing structures and institutions and emerging needs and desires of nonwestern contexts drawing on the example of aoshima junior high schools surfing bukatsu this article offers a rich contextual contribution by offering insights into how the lifestyle sport of surfing is currently being incorporated into the japanese public education system and the emergent meanings given to both surfing and the bukatsu educational system detailing the changes and continuities as the new sport of surfing and traditional bukatsu system converge we examined the currently unfolding redesigning of japans pe programs through lifestyle sports with a focus on the shifting meanings of social hierarchy competition and community within the bukatsu system first through this study we see how the incorporation of lifestyle sports into japans pe program has helped reimagine entrenched ideas of social hierarchy that have long defined the bukatsu system this was a social structure defined by the senpaikohai relationship emphasizing respect for seniority following a chain of command and favoring group unity over individual outcomes 2122 research suggests that this downward collectivism may lead to notable negative impacts on youth psychological development resulting in considerable social debate on how to make bukatsu more inclusive 112228 to this end the incorporation of surfing into this traditional bukastu system has opened new spaces of negotiation for these conventional social relations in the first year of the surfing bukatsu the intention of the school principal was to align the club with the ministrys principle aim of fostering a sense of group solidarity by maintaining traditional senpaikohai social relations and providing topdown control over the surfing space and place through regular scheduled practice times in the schools swimming pool over the year it became clear that the conventional organization and social hierarchies did not align well with the surf bukatsu or the students hopes and desires following concerns from parents and students and a change in the head principal the second year of the surfing bukastu saw a transformation into a more flexible form of bukastu activity where advanced students were allowed to take time off from scheduled group practice for individual training with the guidance of their parents this also loosened the conventional social hierarchies between senpai and kohai as well as altering the teaching advisors ideas of students guidance and governance a new collectivism was formed new meanings of group unity and collectivism were fostered based on mutual respect personal choice selfautonomy and the recognition of individual differences in needs and desires the new collectivism was described as more horizontalsidebysidethan downward in terms of social structure more flexible in terms of the clubs organization and operation and catering more to each students individual needs than giving priority to the group social interaction identity development and reinforcing the connection between youth and their local environments were some of the expressed outcomes of these changes the support by the students parents and educational staff for reorganizing the surfing bukatsu in this way supports previous research suggesting that lifestyle sports may better align with the changing interests of todays youth its potential to be more inclusive and that social benefits for students can be derived from such sporting activities 123642 for readers unfamiliar with japan such changes may appear minor but those familiar with the bukatsu system understand these to be significant transformations of the bukatsu educational system with potential implications for society more broadly if adopted more widely we argue that changes to the pe curriculum enabled through lifestyle sports can also transform social relations as youth move forward into their careers and adulthood second the article raised concerns about the role of competition as lifestyle sports become increasingly incorporated into the pe systems in japan and potentially abroad research suggests that the informal and noncompetitive character of lifestyle sports helps to foster the physical psychological and social benefits associated with their incorporation into pe curriculums 1214 however the case of the surfing bukatsu within the japanese context shows how maintaining an informal flexible and noncompetitive approach may prove difficult as the powerful sporting and educational institutions seek to maintain an historically embedded competitive approach which aligns with the global and olympic agenda of the growth expansionism and professionalization of lifestyle sports in japan and around the world this study revealed a possible future tension between the suggested benefits of an informal approach to lifestyle sports in pe curricula and the competitive disposition of traditional bukatsu activities several of the interviewees emphasized the importance of developing and expanding on the surfing bukatsu competition even expressing a desire to make it a national competition and thereby legitimizing the surfing bukatsu as a real sport parents of the advanced students the former principal the surf coaches and the teacher advisors saw the competitive component as an important motivator to students competition was also considered an important tool for the promotion of the surfing bukatsu and consequently promotion of the school gakko tzukuri to help attract more students yet others described surfing activities as part of a new school culture and engaged in bukatsu activities with a spirit of just having fun in these descriptions the most fundamental benefit of this surf space was that it allowed students to beatease with themselves with nature and in society the sense of being free from competition hierarchy seniority strict rules and simply enjoying the company of friends sharing time and being together in the sea was something that many students valued parents and advisors also noted that the informal aspects of the surfing bukatsu had a positive impact on the students physical and educ sci 2023 13 1111 20 of 24 mental wellbeing placing too much emphasis on competition could potentially diminish the expressed benefits that an informal approach to lifestyle sports offers students to be clear the surfing bukatsu at aoshima is currently not defined by a domineering competitive attitude moreover competition itself is not inherently a bad thing however the ideologies of perseverance long practice hours strict social hierarchies and corporeal punishment that come along with traditional competitive bukatsu create conditions that may evolve into a more competitive structure for the surfing bukatsu in the future if social practices institutions ideologies and power structures that surround the newly forming surfing bukatsu remain within a traditional competitive framework it is difficult to imagine a situation where the increase in competition would not lead to a similar structure of other bukatsu activities this could even be the most likely outcome as more and more schools across japan establish surfing bukatsu and competition to attract students intensifies competitive surfing is becoming a marketable tool for school promotion in peripheral coastal regions if this happens there is a concern that the students and parents like those in this study who seek the benefits of the noncompetitive informal style and structure of surfing bukatsu activities may hesitate to join thereby repeating the issues and concerns associated with traditional bukatsu activities as wintle 42 writes for some participants an element of competition can be a motivating factor whilst for others it is not pe teachers should carefully consider how competition is presented competition might not be for everyone or appropriate at all times allowing some choice in this area is perhaps key there is room for debate on the advantages and disadvantages of focusing on competition or informal surfing and how to best balance them through bukatsu activities in the future perhaps new meanings of competition could also be reimagined through the incorporation of lifestyle sports within pe curriculums shifting attention from competition to community this study shows how the incorporation of lifestyle sports into pe curricula requires community engagement the new and emerging connections between the surfing bukatsu the local community businesses and the natural environment have demonstrated the necessity of community engagement the literature in japan 10 and in the west 42 suggest that establishing greater connections between pe programs and the local community can increase the likelihood of maintaining physical activity habits as an adult king and church 13 further maintain that participation in lifestyle sports can enhance the bond between students and place and foster community building within pe curriculums these authors argue that incorporating lifestyle sports like surfing into the public education system may have a greater capacity to connect students with their local environments other research has shown that despite the global growth of lifestyle sports increasing demand from students and recognition of the beneficial outcomes there has been a reluctance to incorporate them into school curriculums 1214 this is because integrating lifestyle sports into pe curriculums is relatively uncharted territory that requires further planning organization and resources that many schools do not have 1536 concerns around logistical issues lack of time funding safety and access to resources and facilities are some of the key constraints 14 this study demonstrates that collaboration with the surrounding community is an important step forward to connecting schools with the local community it is argued that traditional sports bukatsu in japan are often limited to school activities and are not connected to the local community 10 this was epitomized in the first year when the surfing bukatsu had to practice in the schools swimming pool however due to the nature of surfing it was found that regular activities must take place in the ocean a community space the bukatsu becomes visible to the community with their presence felt daily this study demonstrates how this attracted new assemblages of cooperation with local business religious groups large airlines and hotels that all enthusiastically supported their efforts in addition as the teachers did not have the qualifications to be surf coaches an external advisor was necessary for the technical and risk management aspects of surfing instruction many of these new relations were more emergent than planned which indicates that the surfing bukatsu could be considered a fusion with community a term which otake and ueda 10 suggests is more intricately embedded than a concept of cooperation one important aim of lifestyle sports in pe curriculums could be to promote a holistic system that does not begin and end at the boundaries of school facilities leading the way towards a reorganization of school sporting activities understanding the emergent meanings experiences and practices as observed through this study of surfing bukatsu offers initial insights into the possibilities and limitations of the transition from sports clubs in schools to community sports characterized as a fusion of school and community by offering detailed insights into the case of aoshima it is hoped that these findings may help to inform understandings for other schools and for other sports as lifestyle sports become increasingly incorporated in pe programs across japan and throughout the globe conclusions and future directions this study offered contextual insights into the shifting meaning experiences and practices of social relations competition and community engagement as they are currently unfolding in the context of bukatsu reform in rural japan doing so we showed how the incorporation of lifestyle sports in pe has the potential to encourage a coconstitutive studentschoolcommunity revitalization in emphasizing the cultural specificities of the emergent meanings experiences and practices of lifestyle sports within the bukatsu system the findings of this study are not intended to be generalizable or to evaluate such programs as good or bad or better or worse rather the intention was to offer detailed understandings of how the lifestyle sport of surfing is currently being incorporated into the public education system in japan to examine the transforming meanings and experiences of both surfing and bukatsu that result doing so we highlight the importance of examining the culturally and sitespecific character of how lifestyle sports are assembled in different contexts especially in lesserresearched nonwestern ones we argue that by paying greater attention to particular histories and sociocultural relationships informing the incorporation of lifestyle sports into public education systems in specific cultural contexts the field will be in a better position to understand the different ways that lifestyle sports are being localized into public education systems as they continue on the path of global expansion knowing such details will help to ensure that the professionalization institutionalization and globalization of lifestyle sports does not turn into the flattening out of sporting and pe social cultural and sitespecific difference and diversity as a relatively new field of study the findings presented here are subject to change as lifestyle sports continue their rapid trajectory towards increased institutionalization and professionalization around the globe in japan the surfing bukatsu is still in its early development and further research is required to examine the longterm effects of incorporating surfing into the public education system the longterm implications of the shift towards flexible nonhierarchal less rule based and noncompetitive socialization as youth become working adults and how this institutionalization may also transform lifestyle sports and surfing culture throughout japan future research offering empirical and culturally specific insights into a diverse range of new meanings experiences and histories in other nonwestern contexts would further our understandings of the multiple and varied functions of lifestyle sports as they increasingly become incorporated into pe curriculums across the globe data availability statement data is unavailable due to privacy or ethical restrictions acknowledgments the authors would like to thank all the participants of this study for their for their warm welcome in the midst of the pandemic we would also like to acknowledge the anonymous reviewers for the time and careful consideration we are deeply thankful to daijiro yamagishi for his referencing language support and friendship throughout this entire process the first time we introduced the theme of lifestyle sports and bukatsu was in a brief nonpeer reviewed student forum at wakayama university 80 author contributions et ad contributed to the production interpretation and analysis contained within this article all authors have read and agreed to the published version of the manuscript funding this research received no external funding institutional review board statement all subjects gave their informed consent for inclusion before they participated in the study the study was conducted in accordance with the declaration of helsinki and was conducted in japan in accordance to the research integrity and research ethics guidance provided by the japan society for the promotion of science informed consent statement written informed consent was obtained from all participants involved in the study

physical activity levels among youth have declined globally during the twentieth century in japan the context of this study this trend is evidenced through decreasing participation rates in school sports bukatsu extracurricular club activities where youth participation in sport and physical activity have become a growing concern research suggests that incorporating lifestyle sports into the public education curriculum may better align with current youth trends thereby helping to address these challenges but little empirical research exist particularly outside western contexts the purpose of this study is to address this gap by offering contextual insights into how the lifestyle sport of surfing is being incorporated into the public education system in japan and how this transforms the meanings of both surfing and bukatsu in new and interesting ways drawing on the case of aoshima junior high schools surfing bukatsu ethnographic fieldwork was conducted over a twoweek period in july 2021 and included participant observation focus groups with students and parents and 22 indepth interviews with various stakeholders three themes emerged that guide the interpretation and discussion 1 a new collectivism fostered amongst members of the surfing bukatsu 2 a contest ed surf style that marked a tension between the competitive and the informal benefits associated with lifestyle sports and 3 the role of surfing bukatsu in schoolcommunity revitalization the study shows how incorporating lifestyle sports in pe curricula has the potential to encourage a coconstitutive practice of studentschoolcommunity development

introduction background american indians continue to have the poorest fiveyear relative survival from cancer in comparison to all other ethnic and minority groups in the us vs 590 for ais 12 cancer incidence rates vary among ai populations and frequently differ from rates seen in nhws living in the same geographic region 3456 data show that ai cancer incidence rates have increased 789 and that the burden of cancer continues to escalate in this population 10 cancer incidence and mortality are consistently higher in ais from the northern and southern plains with higher rates for breast lung colorectal and cervix cancers than nhws living in the same region 11 in most cases increased mortality is due to diagnostic delays resulting in advanced stage of disease at diagnosis and an increased risk of dying from cancer 12 patient navigation programs can help to address such disparities overview of nnacc native navigators and the cancer continuum was implemented to help address this growing cancer health disparity among northern and southern plains ais nnacc was funded by the national institutes of minority health and health disparities from 2008 to 2014 it was a community based participatory research study among 5 partners native american cancer research corporation co intertribal council of michigan mi rapid city regional hospitals walking forward sd great plains tribal chairmans health board sd and muscogee nation ok with statistical analysis through southeastern program evaluation ky the goal was for the partners to collaborate refine expand and adapt navigatorcommunity education programs to address the ai communities and patients needs throughout the continuum of cancer care the research question was can a native specific comprehensive navigatorimplemented community cancer education intervention improve health behaviors among native american community members the study intervention implemented and evaluated 36 series of 24hours of community education workshops at each site content addressed topics within the full continuum of cancer care native patient navigators implemented and evaluated the workshops using an audience response system to collect demographics preand postworkshop knowledge attitudes and behaviors and workshop evaluation and satisfaction each partner had an independent online evaluation program for uploading workshop data and summaries as well as to document npn interactions with workshop participants related to obtaining cancer screening or receiving supportive navigation care workshop content was designed to increase participants abilities to make informed decisions about personal health behaviors encourage healthy practices such as taking part in cancer screening or being supportive of those diagnosed with cancer and to help family and friends improve their behaviors the workshops also were designed to increase the visibility of npns within their respective communities npns created 2 memoranda of agreement per year with a local organization that served ais each organization coordinated and implemented the workshop series as well as 2 family fun events methods social ecology theory the research team used the social ecology theory to guide development of the intervention this theory begins with the individual and facilitates identifying cues to action to meet goals or overcome barriers selfefficacy was integrated into workshop content and included interpersonal concepts by including family and friends as well as referring participants to local resources to reinforce and support healthier behaviors organizational concepts were addressed through the annual memoranda of agreements with local ai organizations the theory cycles among the concepts to reinforce behaviors or if new barriers emerge to help the individual identify new cues to action to overcome barriers and to interact with more or other community organizations and so on native patient navigators and navigator training dr harold freeman initiated the concept of patient navigation and described navigators as those who work directly with individuals to facilitate timely access to healthcare by eliminating or navigating barriers that may impede care 13 they primarily work in medical settings but also can work in the community to inform about and provide timely access to recommended examinations in cancer care a critical function is to eliminate barriers to timely diagnosis and treatment in those who have abnormal or suspicious findings navigators may be lay or clinical the navigators used in this project were called native patient navigators all were lay navigators who relied on the patients healthcare provider for medical information and guidance when navigating the patient in preparation for teaching the education workshop series and assisting patients and families with accessing cancer care services and resources the npns received more than 200 hours of intensive education and training during the 1 st year of the project topics covered the cancer continuum and ranged from protection of human subjects confidentiality and hipaa to basic cancer concepts and treatment and management of specific cancers trainings also included learning how to collect knowledge attitude and behavior data before and following the workshop sessions and incorporated practice exercises to reinforce the new behavior or skill set each topic required 90120 minutes for content and practice quarterly updates and new topics were presented in subsequent years these topics were suggested by the npns to address issues they were facing or were requested by nnacc supervisors based on identified gaps in npns skills and varied by the needs experiences and prior education of the npns in addition to facetoface sessions followup education included having the npns practice teaching a module to others through webinars or with their local nnacc administrator or through roleplaying with each other many complex topics such as cancer treatments or clinical trials needed 3 repetitions before the npns felt they truly understood the topic and could present it to others almost all facetoface inservice trainings were videotaped and the raw footage provided on dvd for review as refreshers and to augment training of newly hired npns additional trainings varied by site training was reinforced through debriefings with the npns and their local supervisors community partnerships twice each year each npn identified an organization that provided services to local ais and approached the organization to determine its interest in partnering to implement the intervention for those that agreed a memorandum of agreement was created between the local ai organization and the nnacc partner each local organization had several responsibilities promote the ai community education workshop series to organization members or frequent users of the organization • recruit at least 35 unduplicated ai community members to attend the workshops • coordinate logistics and host the workshops and family fun events • assign a specific audience response system keypad to each participant and ensure that repeat participants receive the assigned keypad at both workshops and family fun events • retain and update lists of all participants and their specific keypad numbers and distribute keypads at each session • disseminate the 10 incentives to participants after workshop completion • assist the npns to prepare and share easytounderstand findings with those who took part in the workshops as well as to the organizations communityatlarge the local organizations generally were different for each workshop series however some organizations coordinated more than one workshop series over the duration of the intervention benefits of having the local organization carry out the logistics recruitment and hosting were twofold 1 partnering allowed the npns to focus on comprehensively teaching the workshops and 2 the organization was able to integrate the nnacc workshops with other outreach services without having the pressure of learning or teaching new content nnacc intervention the nnacc intervention was composed of two parts a series of education workshops and 2 family fun events the education intervention included 36 series of npnimplemented education workshops each workshop series consisted of 24 hours of content that addressed the full continuum of cancer care the purposes of these workshops were to increase cancer knowledge and increase the visibility and accessibility of the npns who were available to schedule screening appointments carry out followup recommendations and provide support and education for those diagnosed with cancer all workshops lasted from 1 to 2 hours and included audience response system data collection of demographics preand postknowledge attitudes andor behaviors and workshop satisfaction evaluation sessions included participant learning objectives education content on a specific cancer topic discussions question and answer periods and participant interactive activities designed to help the participant practice or recall information shared during the workshop two family fun events were held in conjunction with each workshop series the first occurred prior to the initiation of the workshop series to promote the workshops and collect baseline data the second occurred at least 3 months following completion of the workshop series and was used to collect demographics assess knowledge retention and disseminate workshop findings all workshop participants their families and the local organizations communityatlarge were invited these events lasted 23 hours and included food and family activities such as bingo dance competitions and health fairs easytounderstand summaries of the findings were described orally and provided to all participants online evaluation an online evaluation program was created by nacr in 2006 14 and refined by the partners for the nnacc project each partner had its own online evaluation program with the pi having access to all the npns uploaded demographic preand posttest summaries and workshop evaluation satisfaction data following each workshop the online programs allowed the pi timely access to each partners accomplishments and data to generate summaries and reports 15 similarly each partner was able to generate reports for its own uses and provide summaries to tribal councils and health boards and the community through local newsletters the online evaluation program included tabs on components such as partnerships products dissemination navigation and nnacc workshop summaries the navigation tab documented how many minutes the npn spent with each patient per visit and what tasks were complete reports could be generated by each partner from its independent online evaluation database and allowed the npn to generate summary reports specific to a particular workshop series this information was used in the workshop series summaries disseminated during the second family fun event findings study aim 1 expand and enhance navigator community education inservice trainings and modify the native american community education workshops to include the full continuum of cancer care navigator education for previous projects consisted of 80hours of inservice training sessions however nnacc was a much more extensive project thus the nnacc administrative team collaborated to expand the training to 200 hours most of which was completed during the 1 st year of the study after year 01 quarterly updates provided facetoface through webinars or by roleplaying were presented to ensure the npns remained up to date with the workshop content their teaching skills and knowledge about local cancerrelated resources and services the administrative team modified or developed almost all the possible workshop topics during year 01 of the study to assist with this process each partner identified community leaders to serve on a local community advisory committee this committee provided guidance for what should be included for local cultural and geographic relevance for each topic the draft versions of the workshops were reviewed by local focus groups and through pilot tests at least 4 workshop topics were included in the cancer continuum categories of prevention early detection survivorship and palliative care study aim 2 implement and evaluate 24 hours of native american community education workshops to at least 738 unduplicated native americans in conjunction with each partners community organization the topics for inclusion in the 24hour workshop series were selected the original aim was to reach 600 unduplicated participants however the administrative team greatly underestimated the ai community response to the education intervention and onlyestimated average workshop sizes of 1520 however as word spread throughout the communities about the the workshops the number of participants in each group increased with some groups growing to 4060 participants early in the initial workshop series this enthusiam led administrative team to submit an amendment to the western irb during fall 2010 to increase the number of participants as is evident from table 1 the partners reached 1964 unduplicated participants far surpassing the initial 738 proposed number of participants in the original application although the intervention was tailored for ai cultures people of different racial and ethnic groups took part the education intervention reached people of all ages regardless of how individual partners initially targeted specific age groups table 1 displays the demographics of the unduplicated participants for which there are data study aim 3 during years 02 through 04 the native american community education workshops will increase the knowledge and intended behaviors among the native american participants by at least 20 each workshop included 34 irbapproved knowledge items the same items were used for both the preand posttests all items were multiple choice the content for all items was included in the workshop discussion andor reinforced during the participant interactive activities the percentage of increased knowledge for the study aim was set based upon the administrative teams successful experience with previous education interventions of 15 however this goal was surpassed with an overall increase for all partners averaging a 284 increase the npns also administered multiple choice items to evaluate the successfulness of and satisfaction with the workshops table 2 also summarizes these scores the ai community members rated the workshops very favorably of note are the very high scores for muscogee nation that confirm the great need and acceptance of education as that provided through the nnacc education intervention rcrh scores were low due to npn staff turnover at the end of year 01 once the new npn had been trained throughthe nnacc inservice videos and peer education her rcrh evaluations for the last 18 months of the intervention were comparable with the other partners as shown above 1964 unduplicated individuals participated in the nnacc educational workshop sessions during the project period however when combining the unduplicated participants with those who attended more than 1 workshop session the total number of participants at all sessions was more than 4000 attendance varied by session type the tobaccolung cancer sessions had the highest percentage of overall attendees and the palliative care sessions had the lowest percentage of overall attendees postsession knowledge scores increased from presession knowledge scores for all session types the largest increase in participant knowledge was for the prostate cancer workshops which showed a 35 percentage point increase in mean pre to posttest scores the workshop with the smallest increase was the tobaccolung cancer workshop sessions which only showed a 15 percentage point increase in mean pre to posttest scores mean knowledge scores increased across demographic characteristics when comparing preand postsession data from all sites and sessions looking at specific demographic categories mean knowledge score increased throughout the intervention mean pre to post score percentage point increases were 23 percentage points however some groups showed increases in mean pre to post knowledge scores that were at least 3 percentage points more than the overall increases these groups included pacific islanders asians nonhispanic whites hispaniclatinochicanos and those with some college education but no degree in contrast other groups showed increases in mean pre to post knowledge scores that were at least 3 percentage points less than the overall increase these groups included those aged 6580 and those with less than high school education study aim 4 during years 02 through 05 navigators will provide oneonone support for native american cancer patients and families identified in the course of the education intervention throughout the intervention period the npns provided navigation services for a total of 77 ai cancer patients in addition npns assisted numerous workshop participants to find resources for other medical conditions such as cardiovascular problems arthritis weight management and diabetes the npns documented the evaluation and support they provided to and for cancer patients and their family members using the online evaluation database all npns obtained appropriate hippa approvals prior to accessing any patient information or accompanying patients to healthcare visits the npns successfully assisted 77 cancer patients to access quality and timely stateofthe art care most patients began receiving care within 1 month of a positive cancer biopsy this time frame is a significantly shorter interval from diagnosis to initiation of treatment reported elsewhere for ai cancer patients 161718 each partner provided support differently for example the npns in south dakota directly assisted patients and had a pipeline directly into rapid city regional hospital where the hospital navigators continued to provide support services in michigan the ictmi npns assisted survivors to get into local clinical services and continued to help them for cancer treatment issues addressed at the local clinic however the patients were referred to contracted health services for surgery radiation chemotherapy and adjuvant therapy in oklahoma the muscogee nation npns continued to work with family members facetoface and over the phone they also helped coordinate applications with contract health services to refer patients for cancer treatment and care most are referred to clinical facilities in tulsa but others are sent further away to access the care needed while the patient andor family members took part in cancer care outside of the area the npn was available via phone to help the patients remotely in colorado the nacr npns have strong relationships with local hospitals they obtained hipaa permissions for each patient and accompanied the patients andor family members for many of their appointments at the hospitals all the nacr npns continued to interact with the cancer survivors identified during the intervention for the those who passed during the study the nacr npns assisted with obtaining palliative care thus the npns from all sites provided navigation services throughout the full continuum of cancer care conclusions community participants primarily were american indians ranging in age from 18 to 95 the majority were females their interest and willingness to take part in the education intervention was much greater than anticipated rather than the intended 738 participants the final sample included

the project goal was to collaborate refine expand and adapt navigatorcommunity education programs to address american indian communities and patients needs across the continuum of cancer care prevention through endoflife the intervention consisted of 4 to 6 sitespecific education workshop series at all 5 sites each series encompassed 24 hours of community education the social ecology theory guided intervention development community members from each site helped refine education materials following extensive education native patient navigators npns implemented the workshops referred participants to cancer screenings helped participants access local programs and resources and assisted those with cancer to access quality cancer care in a timely manner

abstract the way people participate in decision making has radically changed over the last few decades technology has facilitated the sharing of knowledge ideas and opinions across social structures and has allowed grassroot initiatives to flourish participatory civic technology has helped local communities embrace civic action on matters of shared concern in this case study we describe sensei a yearlong participatory sensing movement local community organisations decision makers families individuals and researchers worked together to cocreate civic technologies to help them address environmental issues of shared interest such as invasive plant species abandoned items in the forests and nice places over 240 local participants have taken part to the different stages of this year long process which included ten community events and workshops as a result over a hundred concrete ideas about issues of common interest were generated nearly thirty civic tech prototypes were designed and developed along with hundreds of environmental observations in this paper we describe the process or orchestration of this initiative and present key reflections from it 10 every interaction between people and civic technology is a deliberate and intentional act of public participation as such public participation in ps can take different forms from the person collecting data about predefined issues the person collaborating with authorities to monitor issues predefined by authorities the person cocreating solutions to address issues of shared concern the person who ideates civic actions to the person who disrupts established processes by passive nonparticipation or negative participation introduction in the past five years hci has seen a civic turn which has resulted in a rich body of study about the interplay between civics and technology 58 research in the wild 12 participatory design 14 speculative design 5 and action research interventions 1 to study this interplay in community settings have increased in popularity current hci research is facing a growing challenge to improve the quality and sustainability of research project outcomes the field is moving away from being confined to the design and deployment of consultation technology 7 towards a process of working alongside local communities to create and deploy civic technology that addresses matters of shared concern 24 13 14 15 in this paper we describe the process of cocreating a year long participatory sensing movement between local people municipal officers and community organisations around environmental issues of common concern the approach focused on supporting the creation engagement and sensemaking of civic technology while embracing different types of public participation we used different methodological approaches to get an understanding of the pressing needs of the different stakeholders their motives for engaging with this initiative how they imagine civic technology can be used and how best to codesign with them this research was done in seven stages expanding on previous work on sustainable community engagement using civic technology 2 and following an inthewild approach 12 the key contributions of this paper are threefold outline the application of hci approaches to inform and orchestrate a community initiative around issues of shared concern give insights into the use of participatory sensing in nurturing and supporting longterm sustainable practices outline learnings that could be helpful for future cocreated environmental participatory sensing systems the sensei initiative figure 2 sensei approach based on city commons 2 and speedplay 6 sensei is a community initiative that aims to show how technology and participatory practices can be combined to monitor issues of shared concern make sense of data and solve problems collectively officers from environmental management neighborhood participation and services development in the municipality were involved in the entire process metalo 1 played the role of community 1 metalo is an ngo and a community centre used for activities for everyone in town coordinator liberty bell 2 shared their field research tools for community monitoring projects the 2 liberty bell is a field research platform using smart bycicle bells and wristbands to gain insights into the experiences of people on the move researchers informed and orchestrated the process of the initiative using novel research frameworks from hci research 2612 over 240 participants aged 7 to 85 years of which 212 were finnish speakers and 28 were english speakers were involved over a period of 10 months ten events and workshops generated over 100 ideas about issues of shared interest 28 civic tech prototypes and dozens of sensemaking artifacts including data interactions analysis of datasets and data sculptures a platform for environmental monitoring including sensing devices a website and apps was built during this process this platform has been used for 90 days during 2018 by 64 people to monitor environmental issues in town method our approach combined two frameworks which draw inspiration from action research design thinking participatory design agile development and an inthewild approach i the city commons approach by balestrini m 2 and ii the speedplay framework by ferrario ma 6 the city commons is a novel approach to orchestrate community engagement around issues of shared concern enhancing community ownership openness skills development and prompting discussions about data privacy ownership and governance 2 whereas the speedplay framework enables the development of software in a rapid and agile manner with an emphasis on participatory reflection 6 we saw an opportunity to combine the orchestration features from the city commons with the technical advantages of speedplay to engineer technologies using agile development iterations as a result the initiative followed seven stages in an iterative manner goals and outcomes for each of the stages are detailed in table 1 stage 1 identify this stage was focused on i identifying matters of shared concern and ii mapping out communities decisionmakers organisations and other bodies that might be interested in working together to find solutions 29 the following activities were carried out • online mapping of matters of shared concern the researchers mapped online conversations on discussion forums news and social media to create a preliminary understanding of the issues in town these discussions had increased around environmental issues such as smells and pollution in the last 3 years • local stakeholder identification a preliminary meeting was set up with municipal officers to understand their work and challenges the matters mapped in the previous activity provided a good focus for discussion about their relationship with local people this meeting led to the creation of a list of existing associations community groups and municipal offices that could be interested in working together to find solutions for issues of shared concern subsequently these potential stakeholders were contacted • partnership conversations direct phone calls emails and partnership meetings with stakeholders a range of neighborhood associations municipal offices ngos and community groups led to the creation of an initial map of existing municipal priorities which included issues such as smells noise alien plant species blue algae and litter commitments for future actions through a crosscultural partnership agreement 11 which articulated our common intentions actions and goals including specific responsibilities ethical and legal guidelines this agreement allowed the initiative to continue despite the lack of official funding because every partner committed to provide some resources for the initiative including expertise time and materials a plan of public activities including workshops and public conversations in order to open the initiative to everyone and help reach a common understanding of the shared matters of concern in the local community • public conversations this activity entailed talking to people in places where they congregate municipal officers individual volunteers and the researchers set up a popup shop in the citys shopping centre and mingled with people talking about their concerns about local environmental issues and inviting them to upcoming initiative events stage 2 frame the aim of this stage was to i understand the matters of shared concern ii map the individual motives of the participants to adjust the shared purpose of our initiative and iii explore the possible uses of technology to address the matters of shared concern this stage included cocreation workshops where a number of design thinking and scenario techniques 3 were combined the techniques used in this stage were selected to boost ideation deliberation and creativity among participants they included introductions and icebreakers rapid ideation charrette discussions and reverse thinking ideation workshops two workshop open days were organised at the community centre to continue identifying matters of common concern and deepen the understanding of those issues the facilitators were municipal officers individual volunteers and the researchers over 50 people attended these events in total the workshop programme included activities of i introduction and icebreaking ii rapid ideation produce as many ideas as possible pin them on a large scale wall map share your thoughts with others iii charettes about what are the matters of concern you would like to monitor in town why are they important for you iv reverse thinking about how would you monitor matters of concern if technology did not exist as a result over 100 suggested matters of concern resulted from brainstorming these ideas were analysed and grouped together into 10 main matters of concern participants often illustrated ideas by providing examples from their day to day experiences it quickly became apparent that environmental issues positive and negative were of greater interest to participants over other topics for example sharing knowledge about good places in town was a popular idea negative issues such as abandoned items and litter were often suggested stage 3 imagine the goal here was to understand the participants aspirations and requirements this was achieved through cocreation workshops that drew basis from design thinking usercentred design and participatory design prototyping workshops two open workshop days were organised at the community centre to codesign technology prototypes that would focus on the identified matters of shared concern these workshops followed similar organization structure as the framing workshops over 50 people attended these events in total the workshop programme included rolestorming and prototyping 28 prototypes were developed by the participants these prototypes included i wearables for hand foot arm wrist head ii mobile apps iii attachment to other things eg headphones necklaces gloves paddleboards paddles bracelets walking sticks steering wheels iv characters eg a remote duck to monitor algae a virtual pet dragon a neighborhood watch cat we quickly realised that mobile applications were a common denominator to all these prototypes participants would often describe their prototypes as part of a platform which they could access from their own smart devices stage 4 create prior to commencing stage 4 in selecting the issues of shared concern we needed to strike a balance between the issues participants had highlighted in the workshops and issues the municipal environmental office were tasked with monitoring as a result the chosen issues were invasive plant species nice places in town and abandoned items in nature in this stage the tools needed to address the chosen matters of shared concern were created participants critiqued and pilot tested the prototypes an agile approach for prototype development was taken with ten days long iterations as a result the sensei platform was created a platform using frontend bluetooth devices such as bicycle bells wristbands and sticky buttons which participants could press to report an issue eg one click invasive plants two clicks nice place hold 3sec abandoned items these devices were connected to a mobile application that allowed participants to submit photos and create private monitorings the created technology was deployed in the wild and iteratively improved stage 5 allowed us to understand how participants interacted with the technology in their everyday life without instructions a total of 64 locals volunteered to use sensei over a period of 12 weeks this pool of participants included local people who had attended the workshops others who were recruited by the workshop participants themselves and those who had heard about the initiative from the partners a total of 300 observations were recorded on sensei stage 6 orchestrate meetups were regularly organised with participants to discuss their concerns and gather feedback about the platform educational materials about the issues being monitored were distributed by post directly to the participants a public interactive exhibition was organised to support sensemaking with civic data the data collected in the sensei platform was used to create several urban data games designed to familiarise people with the datasets collected through social interactions both direct interaction through conversation or indirect interactions through text or data artefacts left in public view stage 7 sustain a workshop to discuss the future of sensei was organised with the participants the discussions focused on technical improvements and new civic actions the participants cocreated a report on the data collected by sensei assisted by researchers and the report will be brought to municipal decisionmakers to inform their work • facetoface multiconstituency communication sustains engagement direct communication with the participants and decisionmakers involved helped raise awareness about the approach enhanced public engagement and resulted in clear commitments by all those involved the workshops allowed consensus to be reached as differences arose over the selection of what should be monitored giving communities a voice is a powerful way of harnessing their wisdom however it also means that expectations need to be managed in a timely way • welcome different types of participation over the course of the identification stage it became clear that individuals wished to get involved at different levels some were interested in the workshops whereas others wanted to get immediate access to tools as a result we had to reorganise our call for public participation into two strands i those wishing to get involved in the workshops and ii those wishing to use the resulting creations for civic action lessons learned and key reflections it was important to be flexible and allow for changing dynamics over the course of the process designing for different levels of participation is key to begin to understand the affordances of participatory sensing technologies in the wild • participatory sensing should be designed for diversity across all ages genders and skillsets all events were organised to be as inclusive as possible workshops were held in both finnish and english and balanced the teamwork of participants of all ages genders and skillsets as a result a common understanding with all participants was built organically • identify and fill gaps with knowhow from experts in cocreating technology it is useful to identify and fill any gaps in required technical skills during the imagine stage participants came up with several prototype ideas which required specific technical skills outside of our core skillset liberty bell got involved with a number of devices for the monitoring campaign students worked on the development of the platform and members of the community designed and printed 3d models of the prototypes which allowed us to evaluate the prototypes suitability • enhance sensemaking skills by using civic data our public exhibition helped familiarise people with the datasets collected through playful interactions • enhance the sense of ownership by welcoming critique and suggestions pilot testing with participants in a realworld context is useful for detecting bugs and improving civic tech but also for enhancing a sense of common ownership participants actively tested critiqued and suggested improvements to sensei they also named each of the platform releases conclusion in this paper we describe the process and orchestration of the sensei initiative and present key reflections from it local community organisations decision makers families individuals and researchers worked together to cocreate civic technologies to help them address environmental issues of shared interest such as invasive plant species abandoned items in the forests and nice places the public participation continuum continues to evolve largely due to the rise in civictech which has facilitated activism public campaigning and community monitoring technology has opened up a myriad of communication channels between municipal decisionmakers and the community they serve civic technology and participatory sensing in particular allows local governments to use civic intelligence to identify common causes limited public resources and services can act as a barrier to implementing solutions to the problems identified creators of civic participatory technology should actively seek involvement and cooperation from decisionmakers in order to ensure that the supports and infrastructure are in place to allow innovations to flourish and from which the community can truly benefit

sensei is a community initiative involving locals researchers community organisations and decision makers aiming to understand the challenges they all care about the initiative has shown how technology and participatory practices can be combined to address issues of shared concern make sense of data and solve problems collectively

introduction gender equality is critical in todays world for several reasons gender equality is a fundamental human right every individual regardless of gender should have equal opportunities access to resources and the freedom to make choices without facing discrimination or prejudice gender inequality perpetuates social injustice when individuals do not have equal opportunities based on sex this results in inequities in education employment access to health and political participation gender equality helps create a more just and inclusive society gender equality is essential from a human rights perspective and a prerequisite for achieving sustainable and just development by creating a more inclusive society we can achieve better progress and reach every individuals full potential regardless of gender when linking the urgency of gender equality to islam it is essential to understand that islam has principles that promote gender equality and fair treatment of women the concept of gender equality from an islamic perspective has explored religion to shape gender roles in modern the differences in the work of fathers and wives develop equality regardless of differences in the premodern contained in classical jurisprudence women were treated as second class and placed under male authority gender relations in family law as digital activists support equality in islam in developing male and female relations presidential instruction no 9 of 2000 explains gender equality as the main thing to support national development and equal rights from a legal perspective therefore the sociocultural system opens up a broad civilization in palestine where these rights are considered to weaken the interests of the male elite which are contrary to womens theologically all human actions that harm the environment and world leaders are eliminated from efforts to achieve the common goal of gender equality in 2030 islamic feminists reclaim the ethical vision of the koran by presenting reinterpretations especially of womens verses of equal rights in the family and society in mobility of honour muslims in india play different but ultimately complementary roles in the intrachipa relations of some people in the muslim community with pansouth asian purity and discrimination against dalit muslims during the spread of religious fundamentalism in europe how muslim women dress takes on a narrative of gender equality islamic feminism in india women activists and muslim private law reform feminist universal human rights principles campaigning for the passage of genderneutral civil laws on the authority of the koran over the last few decades the phenomenon of conversion to western society has changed in academics and the mass media regarding the motives of many converts to islam mitchell mamone rane towards the islamization of feminism and the feminization of islam which refers to activists realizing the foundations of political philosophy and ideology of equality the significant egyptian state law against social and financial pressure on relatives ensures the application of marriage rules to the koran turkish invasion and terrorism in the context of slovenia are reflected through global perceptions of islamic civilization towards european science this research differs from previous research in providing a new framework for thinking about gender equality in islam to understand methodologically better using a bibliometric analysis approach bibliometric analysis can help researchers publish documents as the primary basis in cases in the globalization era studying the importance of gender equality in islam as a guide to exploring differences in rights and obligations based on this research formulaspecific questions how is the development trend of studies on gender equality in islam how is the networking and mapping of relevant topics related to gender equality in islam based on these questions it is hoped that women and men will understand more about the equality of rights and obligations in islam so that researchers can raise more specific research problems for future researchers this study uses data sources in the form of research publication documents from the scopus database the scopus database was chosen to help researchers observe the development of global studies related to trends in gender equality in islam the document search was carried out on january 12 2023 searching and filtering published documents does not use certain restrictions on researchers or authors geography type of article journal and year of publication filtering is only determined based on keywords that searchrelated literature search for that keyword with 133 document results after that proceed to combine all the topics research method figure 1 data analysis process the data analysis process shows the steps for collecting data by searching documents published in the scopus database data filtering is used to find relevant documents to determine searches based on abstract titles and keywords the search for documents includes the field of study all documents used include reference articles and books the filtered data results are collected in the analysis software namely vosviewer vosviewer helps publish documents by maximizing data visualization features for more indepth usage analysis results and discussion trends in the development of studies on gender equality in islam publication documents related to gender equality in islam were analyzed from data retrieval results following publication trends on scopus the data displayed is based on a search on the scopuscom website using vosviewer then the data follows the lengthier trend this can influence research not to display data visualization that is less relevant so that it is easy to understand and accessible for future researchers to understand several study muslim scholars highlight the importance of the basic assumptions and models of interpretation that govern traditional islamic legal theory and ethics from several alternative scholarships on gender equality in islam as a developing country malaysia is committed to sustainable development in 2030 and increasing the global gender gap gender equality refers to the equality of men and women so forming an organization is stated for a methodology that is implicit in very active work to date pivotly marginalized migrant minorities acculturated more rapidly as their support for gender equality grew stronger over the years of migrants and focused on essentialist views of the muslim religion this data shows that sometimes there is an increase every year and gender equality in islam sometimes decreases however learning the science of gender equality in islam is deeply studied as a change in sociocultural studies among muslims based on the results of the analysis of search data on the scopus website it was found that there were trends in the scopus database in the last 5 years in 2018 there were 20 documents then increased in 2019 to 24 documents and in 2020 it continued to increase to 33 documents but in 2021 it decreased to 26 documents and continue to decrease in 2022 to 15 published documents analyzed on a database based on the scopus web other studies develop islamic legal discourse through studies to explore assumptions about womens bias or the influence of modern norms the concept of religion and secularity describes the national self and muslim position which is accepted based on the swissgerman media forming an image of identity and ownership of a national identity many middle eastern and south african societies developed and tested gender socialization frameworks that have agency in religiosity as an increase in gender equality parents limit participation in mixed activities to the norms of parenting in the gender welfare state to protect adolescents this data shows that the studies learned from various articles books and others so that they can develop their study talents but use more articles because they think they are relevant to study so that students can understand gender equality in islam those studying the struggle for gender equality is carried out at the international and national levels with the united nations commitment to a 30 quota for women in politics and the public women activists in india argue that politics and religion shape the scope of muslim womens activism in india relations between religion ideology and politics shape peoples attitudes towards the system of political studies domestically and internationally by running a public study organization that continues to grow today social values shape womens access to work in muslimmajority countries to develop a religious conceptualization of gender differential valence as respect as guardians of important traditions for tatar society muslim women are indispensable as defenders and supporters of religious and cultural traditions on 1 may 2017 hundreds of veiled muslim women took part in the international labor day demonstration in gothenburg and highly valued the idea of secularism and including christianity as an integral part of the community established a republican fraternity to promote social reform through a new understanding of divine revelation that emerged during its twoyear khalwa or retreat and embracing gender equality and social justice of the various topics that have developed it is found that the relationship of gender equality in islam is very relevant this is reflected in several documents supporting gender equality in islam so that forming organizations and various fields in the current conditions are still developing their respective differences and equalizing what is being done for the rights of women and men networking and mapping relevant topics related to gender equality in islam religionbased social norms and values shape access to work in muslimmajority foreign countries aimed at developing a religious conceptualization of gender differential valence that functions to produce equality developments in gender equality highlight the importance of the realities of life for quranic hermeneutics proving the dominant and productive model of centralized analysis of sacred texts and religious practices for men discourse on the chhipa muslim obc community examines upward mobility strategies it honours the core of equality for muslims playing different wars and complementing the pure pansouth asian polluting caste practice of pure faith this data shows that 10 significant writers on gender equality in islam submitted documents some of them had 2 documents and there were up to 4 documents and even up to 5 documents this shows that the increase continues to grow in panasian countries the visibility of women and womens freedom in the french public has two very contradictory positions with the existence of antiveil and antiburqa laws relating exclusively to muslim womens clothing and others to contribute to the italian literature on nonmonogamy with psychosocial interpretations of the future with politics and queer familial normativity positions the rights of gender differences arab countries also provide enlightenment for traditional authorities and arouse peoples participation in empathy for fellow citizens to increase religion because the current contemporary era requires gender movement efforts that are more adaptive to the times one of which is through the social media space muslim women who are strong in management roles and their social psychological models that refer to islamic traditions carry out many leadership roles in traditional families men become supporters and thrive figure 5 analysis of coaccurance overlay visualization of gender equality in islam part of developing islamic hermeneutics is one of the main elements of the production of affirmative scholarship on gender equality in islam although conceptually separate religion politics and ideology are often intertwined and relationships are growing and this volume can bring together several expert contributors who explore various issues the movement of struggle takes place worldwide including in indonesia starting from the issue of gender inequality where justice has become a universal need or demand and is the common agenda of every country by applying the approach in muslim countries cedaws understanding of gender equality with a sharia perspective continues to increase with the formation of global media and recreation and a new space for identification with liberalwestern society british muslim women work as cultural producers in stereotyped media fashion strategies and reject socioeconomic exclusion islam is considered an opponent of gender equality which in crisis factors lead to the exclusion of women in modern politics and the role of women in society in addition feminist gender equality has a nature which means justice and respect for women which are legally determined to be correct this data shows that gender equality in islam is still very relative and apparent researchers are very interested in this problem because the development becomes material for consideration related to gender equality in islam the achievement of the goal of friendship between residents and their overseas residents applies to gender equality that is being promoted by progressive islamic groups with indicators of womens rights exploring crosscountry variations islam is a source of womens legislation changing due to the new constitution critical insights into islamic feminism can provide new gender and religious awareness developing further and presenting an interpretation of gender equality in relational approach discourse women won a plurality in the 2011 elections and all parties 31 of seats had the opportunity for gender legislators and an islamist orientation towards womens references as well as increased womens symbolic responsiveness to parliamentary improvement services muslimmajority countries appear to be consistently more patriarchal towards homogeneous cultural groups to support gender equality in globally significant regions argentine society which experienced profound genderrelated social change and became history is always remembered for the growth of feminist and lgtbq activists and the arrival of the progressive argentine government in response to the akps efforts to significantly return gender relations with complementarity and fitrah women across the political spectrum are mobilizing an understanding of gender equality in france gender equality the rights and limits of muslim women are very much defended by the socalled lactate and emancipation of women in arabia it is also increasingly empowering consultative assemblies and representations of women vary enormously in developing models of simultaneous equality demonstrating religious and ethnic gender ideology conclusion this research found 133 relevant publication documents related to gender equality in islam the results of examining the publication documents also found several other relevant topics including gender islam feminism gender equality religions womens status womens rights gender relations family law social media public openings middle est politics women and article these topics can still be developed depending on global researchers interests the trend of the results of this research also helps to study the development of gender equality studies and networks in islam it can also provide a global reference in understanding changes in the perspective of the study to influence the attitude of subsequent research this study is based on the results of an examination of publication documents this could become a reference for future research especially on gender equality in islam both internally and nationally the limitation of this study lies in the filtering of data which is only limited to specific publication years it also affects the number of documents analyzed so further research is needed to explore a more significant number of documents it could affect the results of a better analysis in the future

background gender inequality perpetuates social injustice when individuals do not have equal opportunities based on sex this results in inequities in education employment access to health and political participation purpose this research aims to conduct a bibliometric analysis related to gender equality in islamthe method used is bibliometric which involves collecting and analyzing data from relevant scientific publications from the scopus database this research found 133 relevant publication documents related to gender equality in islamthe results of the examination of publication documents also found several other relevant topics including gender islam feminism gender equality religion womens status womens rights gender relations family law social media public opening the middle east politics women and articles these topics are still subject to development depending on the interest of global researchers trends in the results of this research also help to study the development of gender equality studies and networks in islam this can also be a global reference in understanding changes in study perspectives that can influence attitudes to further research this research is based on the results of examining published documents which can be a reference for future research especially on gender equality in islam both internally and nationallythe limitation of this study lies in data screening which is only limited to specific years of publication 2017 2018 2019 2020 2021 2022 2023 this also affects the number of documents analyzed so further research is needed to explore a more significant number of documents this may affect better analysis results in the future

introduction background cigarette smoking is the leading cause of preventable cancer cardiovascular respiratory and other smokingrelated illnesses and deaths in the united states 1 despite the decline in overall smoking rates in the us population over the past 50 years there are persistent disparities in the prevalence of smoking among vulnerable populations 2 transgender and genderexpansive adultsindividuals who have a gender identity behavior or selfexpression that is different from their sex assigned at birthare twice as likely to smoke cigarettes than cisgender individuals 3 approximately 36 of tge adults smoke cigarettes compared with 21 of heterosexual cisgender adults 3 an estimated 1 million tge adults live in the united states 4 which means that approximately 350000 tge individuals are at increased risk of developing smokingrelated cancers the factors associated with increased smoking prevalence among tge persons are complex and include tgespecific minority stressors including everyday discrimination 56 structural discrimination 6 social determinants and alcohol and other substance use 6 in addition the tobacco industry targets its product marketing and advertising among lesbian gay bisexual transgender and queer communities 78 compounding these risk factors tge individuals lack equitable access to health care and therefore face barriers in receiving smoking cessation interventions 9 research suggests that given the appropriate resources and opportunities tge adult smokers are just as likely as cisgender smokers to want to quit 9 10 11 despite experiencing multiple risk factors of smoking receiving genderaffirming care earlier on recognition of tge status and social support systems may be protective against smoking among tge persons 12 there is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among tge adults of 384 national institutes of healthfunded sexual and gender minority research studies in 2018 20 focused on tge health and only 1 focused on tobacco use and health 13 furthermore although there is increasing evidence of the effectiveness of using social media for hiv interventions among lgbtq populations 14 there is limited research on the use of webbased social media platforms for tobaccorelated research and smoking cessation interventions among tge populations 15 16 17 objectives the objective of project spring is to examine tge individuals experiences of smoking risk and protective factors in closetoreal time by using a photovoice approach whereby participants identify represent and enhance their community through a specific photographic technique 1819 photovoice has been used in prior research to examine the social experiences of tge individuals 20 the rationale for using photovoice instead of existing approaches such as qualitative interviews or quantitative surveys are threefold first we aimed to obtain participants documentation of their experiences of risks and protective factors in close to real time to minimize recall bias associated with interviews and surveys second photovoice enables the exploration of new or emergent risk or protective factors that are not limited by closeended survey questions third the photovoice approach involves multiple interactions with participants over time and enables the collection of multiple types of data from the same participants focus groups at one time point and crosssectional surveys are limited in this regard our approach was guided by a communitybased participatory research approach 21 where tge persons were included as cocreators of knowledge in several aspects of the study including data collection analysis and interpretation to inform future research and interventions this study approach empowers tge persons to work collaboratively with the study team to understand factors influencing their smoking habits and generate evidence to inform future tgetailored smoking cessation interventions this research is informed by an integrated framework of key concepts from the minority stress model resilience framework and socioecological model 2223 we conceptualized smoking behaviors among tge persons to be influenced by both risk and protective factors across individuals relationships community and societal levels findings from the realworld exemplars phrases meanings of smokingrelated triggers and protective factors from this research will serve as the foundation for designing culturally sensitive narrative messages to promote smoking cessation through social media among the tge community methods research design we used a qualitative research design using digital photovoice data collection focus group discussions and member checking among participants the study was approved by the institutional review board of harvard th chan school participant eligibility and enrollment we enrolled a purposeful sample of participants who identify as tge live in the united states have smoked at least 100 cigarettes in their lifetime currently smoke cigarettes on one or more days in the past 30 days use either facebook or instagram at least once daily and were able to participate in english individuals who were currently quitting smoking only used ecigarettes or cannabis did not smoke cigarettes and were not able to participate using the english language were ineligible we used facebook and instagram because of the high prevalence of use of these 2 platforms and increased exposure to tobaccorelated messages on social media among lgbtq populations 2425 the study enrollment was conducted between march 2019 and april 2020 our initial recruitment was in a northeast metropolitan city and we expanded the recruitment nationally in october 2019 we recruited most participants through paid facebook and instagram advertisements based on the best practices of engaging tge populations on the web for research studies 2627 we also used craigslist advertisements snowball sampling posting flyers at lgbtq events and venues and outreach through lgbtq community organizations two study research assistants screened interested participants over the phone and consented participants who were eligible and agreed to participate in the study approximately half of the participants joined separate facebook groups and half joined separate instagram groups the recruitment proceeded on a rolling basis and participants within each group completed the photovoice collection within the same period of 21 days in their respective groups there were between 2 and 9 participants per group all participants in each group were given the same start date participants received gift cards as incentives for completing each phase of the study procedures we received messages from over 330 interested individuals and were able to contact 110 for screening over the phone or through facebook messaging of the 110 individuals 47 were eligible and enrolled in the first phase of the study of the 47 individuals 44 completed photovoice data collection of the 44 individuals 29 participated in the focus group discussion among these 9 individuals participated in the member checking discussion study procedures digital photovoice data collection we used the photovoice technique 18 to obtain participants closetoreal time personal experiences of risk or protective factors of smoking participants were asked to upload pictures and a brief caption of either risk or protective factors in relation to their smoking they experienced to a private studyspecific facebook group or on an instagram group chat daily for 21 consecutive days participants information on the facebook or instagram groups could only be viewed by the participants within their group and the study team participants were encouraged to post at least 1 picture per day for at least 5 days per week to ensure a minimum level of participation in the study they could provide comments on each others posts to ensure their privacy and confidentiality 2 study research assistants conducted training with each study participant to describe the study protocol and examples of the types of appropriate pictures phrases and comments that can be shared within their respective facebook groups or instagram group chats each participant was assigned a unique study id code number not connected to any personally identifiable information focus group discussion after each group completed the photovoice data collection we invited all participants to a focus group discussion with their respective group members a phdprepared nurse researcher with extensive experience and training in qualitative research led the focus groups to research assistants we conducted inperson focus groups among participants from a northeast metropolitan city and conducted webbased focus groups using the zoom web conferencing platform among participants who were recruited nationally the number of participants across the focus groups ranged between 2 and 7 the duration of the focus groups ranged from 70 to 170 minutes during each focus group participants were first shown photos that they contributed within their facebook closed private group or instagram group chat they were asked to work as a group to complete an image sorting task where they first categorized the images as either risk or protective factors for smoking following sorting into risk and protective factors we asked participants to describe each photo categorized as a risk factor in their own words this was then repeated for each photo which was categorized as a protective factor the moderator provided guidance to the group and probed for the rationale for certain categorization decisions using the showed questions as needed participants final categories and names of each category as decided by the groups consensus were recorded the inperson focus groups were audio recorded and for the webbased focus groups we obtained an audiovisual recording and immediately deleted the video component following transcription by a professional transcriber the recordings were deleted per institutional review board requirement for participant confidentiality and privacy member checking following the study teams preliminary analysis of the photos captions and focus group transcripts we invited participants from all the facebook and instagram groups to attend a webbased member checking discussion to obtain insights on their interpretation of the risk and protective factors of smoking behaviors identify the most important factors to address in future interventions and discuss potential approaches for culturally tailored interventions to reduce smoking among tge persons a total of 9 participants were able to attend the member checking focus group the member checking participants were not all from the same initial facebook or instagram group but were members of 5 different groups this member checking discussion was conducted over 67 minutes over zoom web conferencing and we obtained an audio recording following transcription by a professional transcriber the audio recording was deleted analysis photos captions and focus group transcripts were uploaded to nvivo 12 by the study team for coding analyses of photos and captions were conducted in conjunction with the participants during the focus groups after completing the focus groups the study team synthesized the data into related categories furthermore 2 research assistants coded the transcripts from the 2 focus groups to ensure agreement in an initial coding guide each research assistant then coded the remaining focus group transcripts individually emerging codes or questions were resolved by discussion with the study team and the codebook was updated following the discussion the final codebook is available as multimedia appendix 1 we categorized factors as being risk or protective factors occurring at individual relationship or community levels and specific factors we then organized the individual codes into major themes of risk and protective factors this study followed the consolidated criteria for reporting qualitative health research on the basis of recommendations from the literature 28 we estimated that 36 focus groups would be sufficient for theme saturation results participant characteristics saturation of themes was achieved after conducting 7 focus groups between march 2019 and april 2020 with a total of 47 participants the mean age of the participants was 26 years approximately half of the participants were identified as nonbinary or gender nonconforming 15 were identified as male trans male or trans men 17 as female trans female or trans women and 15 identified with other gender identities most of the participants identified as nonheterosexual half of the participants identified with multiple sexual orientations 17 as bisexual 13 as queer 11 as pansexual and 9 as gay or lesbian most of the participants were nonhispanic with 55 identified as white 13 black and 32 other racial or ethnic identities approximately half of the participants were daily smokers and half were occasional smokers in the past 30 days additional details of participant characteristics are summarized in table 1 we compared the characteristics between participants in the northeast city and those recruited nationally and there was no significant difference risk and protective factors overview we identified 6 major themes of smoking risk and protective factors experiences of stress gender affirmation health consciousness social influences routine behaviors and environmental cues risk factors were described more frequently than the protective factors in addition participants experienced certain factors as risk factors in some circumstances and as protective factors in other circumstances stress was a crosscutting factor that occurs at the individual relationship and community levels we describe and illustrate each theme specific codes within each theme organized into risk versus protective factors and indicated which levels the factors were coded in figure 2 we used theythemtheir pronouns in the following section although individual participants may use other preferred pronouns to present the results we reviewed the data to compare the risk and protective factors from participants in the northeast city versus national participants and there was no discernible pattern to distinguish between the 2 sets of participants with the exception that 2 groups from the national sample had discussed experiences related to the covid19 pandemic that were not present in the northeast city participants experiences of stress participants described a variety of stressors linked to smoking behavior some participants highlighted their experiences of minority stress related specifically to their gender identity that were associated with their smoking for instance one participant recounted a fellow colleague who identified as tge being harassed by a customer one of my fellow trans coworkers was harassed screamed at and intentionally misgendered as well as received a torrent of slurs from a woman that came in today and that definitely made us all want to smoke another participant shared a photo of being in an office with their colleagues and having to conceal their identity from them and the following caption i work in an office with all men and most of them are transhomophobic but almost none of them know that im gay or trans and f do they test my patience every day and thats what makes me want to smoke work school commuting transportation financial situation housing and relationship conflicts were factors that triggered increased smoking for some participants for instance one participant shared a stock photo of 2 people quarreling to reflect on a conflict with their partner and this accompanying caption we dont fight much but im a very confrontational person so not getting to finish the argument right away stressed me out to the point of wanting to smoke participants described societal stressors such as homelessness the economy and lack of access to affordable mental health care as risk factors for smoking for example one participant posted a drawing depicting homelessness as a source of their stress and smoking with the following caption this pic represents all the economic issues personal and larger that stresses me out i know there are lots of healthier ways to deal with my financial anxietiesbut cigarettes are cheaper than therapy regarding coping behaviors to reduce feelings of stress participants described using various strategies including achieving relaxation or contentment using humor or exercising for example one participant shared about using humor to help avoid smoking anything that makes me laugh thats like kind of making fun of anything is like helpful and not smoking actually so it feels protective to me because humor helps me get through all the horrors of the world that were living in gender affirmation participants described smoking as one way to affirm their gender identity and experience gender euphoria for instance one participant shared a photo where they were smoking in their car while driving and a caption im a very good driver i believe which is a stereotypically masculine thing and smoking is seen by some people as masculine as well its affirming in a weird way conversely feelings of selfesteem of ones appearance were associated with not wanting to smoke one participant shared an occasion of dressing up and not wanting to ruin their appearance because of smoking i sometimes dress up put on the whole makeup wear some nice type of deal and it kind of ruins that effect when you smell predominantly like smoke and not nice new perfume health consciousness participants viewed receiving gender affirmationrelated health care and health care provider advice to stop smoking as a motivating factor to not smoke for instance one participant shared a picture of having completed top surgery and a caption stating that they wanted to quit smoking so that the scars would heal better another participant described being receptive to their doctors advice if my doctor told me that i had to stop taking estrogen this happened and this happened and i didnt stop smoking you know id stop smoking general health was a factor that participants experienced as risks for smoking in some situations and as protective in other situations general physical health issues such as insomnia and pain or mental health issues such as anxiety and mood were identified as potential risk factors for smoking having respiratory symptoms seeking mental health therapy and practicing selfcare were also described as protective against smoking one participant shared a photo of a cup of tea and stated in the caption that having a sore throat made them want to drink tea and avoid smoking another participant described insomnia and anxiety as triggers of smoking i feel like sleep andor lack of sleep and anxiety are pretty close together i feel like people tend to feel more anxious when theyve maybe not slept very well and cigarettes are one way of like coping with that and sort of addressing that participants were concerned about the health of family members pets or animals around them if they smoked which motivated some participants to avoid smoking one participant posted a photo of being with young children and wrote being with my kids makes me not want to smoke their health and my own makes me always reconsider my choices another participant shared how they would not smoke near their pet to avoid harming their pet because of secondhand smoke i remember reading a bunch of articles about how secondhand smoke affects pets and i really love my cat and i dont want him to get any ill effects from me smoking so whenever i do i try to do it on the porch and i try to lock him out which he hates social influences social influences were described as risks in some circumstances and protective factors in others being in the company of friends and peers in social situations where smoking and other substance use were present were risk factors for smoking one participant explained the following in the focus group there are things that make me want to smoke and seeing anyone else with a cigarette or hearing anybody else talk about having a cigarette is one of those things positive family pressure and friends or peer norms to not smoke were associated with avoiding smoking one participant posted a photo outdoors with their partner and described their partners disapproval of their smoking in the caption my best friendlife partner hates when i smoke so thinking of her makes me want to quit routine behaviors routine behaviors such as driving or drinking coffee were viewed as risk factors for smoking for instance one participant shared a photo of sitting in their car and a caption of being triggered to smoke whenever they drive the taste of cigarettes was another factor within the theme of habit that increased smoking for some participants but deterred others from smoking one participant shared that the taste of finishing one cigarette prompted lighting up another cigarette another commented on cigarettes being nasty and that made them not want to smoke substance use including alcohol and cannabis was also discussed as a risk factor for smoking cigarettes for example one participant shared a picture of a can of beer while playing a drinking game that led to their desire to smoke a cigarette playing a drinking game tonight alcohol always makes me want a cig especially since one of my roommates smokes too and i know hell go out for one at some point conversely having distractions was helpful in keeping participants hands and minds occupied and avoiding smoking these distractions included cooking a healthy meal working on a school assignment occupying their hands by playing a musical instrument viewing positive images and watching entertainment shows environmental cues participants described environmental cues that prompted their smoking including being outdoors experiencing either good or bad weather easy access to cigarettes images related to smoking or being in a bar one participant shared a photo of a rainy day outside their home and a caption cold wet boring and grey day nice time for a cigarette conversely some participants described environments or situations that discouraged them from smoking including places where they were not able to smoke such as at a transit stop and bad weather which prevented them from going outdoors to smoke one participant posted a picture of being at a picnic in a public park and captioned it as follows i love to have a smoke while walking around but it was a public park so i waited until i got home discussion principal findings this study described a comprehensive set of risk and protective factors occurring at multiple levels among a sample of tge smokers based on their realworld experiences and through an analysis of a combination of photos captions and focus group discussions participants in this study reported more risk factors for smoking than the protective factors this was understandable because they were current smokers and did not attempt to quit smoking at the time of the study this information is unique and essential for understanding the circumstances and reasons for smoking and for avoiding smoking among tge individuals most themes of risk and protective factors described by the participants were consistent with prior literature on the determinants of smoking among lgbtq populations 56 however to our knowledge this is one of the first few studies to identify unique factors associated with smoking among tge individuals including gender affirmation and gender affirmationrelated health care these study findings help us understand the important factors that underlie smoking habits among tge individuals which can serve as the foundation for future research and smoking cessation intervention design first there is a need for future research on the underlying factors linked to smoking or not smoking that either occur more frequently or are unique among tge populations although prior literature reported correlations between receipt of treatment for gender affirmation and smoking behavior or smoking cessation 2930 this study adds to earlier research by documenting participants explaining in their own words how gender affirmation and gender euphoria were related to their smoking behaviors this study identifies factors that focus on preventing smoking initiation and promoting cessation among tge populations that have not been previously described such as gender affirmation and receiving gender affirmationrelated health care future work to pretest the relevance and acceptability of health messages that also address the theme of gender affirmation to promote smoking cessation among tge populations will be needed second the images phrases and stories from tge participants lived experiences may inform the design of antismoking messages drawn from authentic testimonials that are salient and culturally responsive to tge individuals for instance participants described reallife situations of avoiding smoking by practicing selfcare in various ways which could be adapted as tips for tge individuals in future antismoking messages third participants described factors that were both risk and protective factors depending on the circumstances and revealed that certain factors occurred across individuals relationships and societal or community levels the findings support the use of a multilevel framework and systems change approach to examine and address smoking holistically among tge populations fourth some participants affirmed the value of the collaborative research approach and provided feedback and enthusiasm for contributing to the research and future intervention design as community advisors we will use a communitybased participatory research approach by meaningfully engaging with tge individuals as coequal partners and advisors during the next phase of this research and in future intervention design these findings are corroborated by several factors in the conceptual framework however some of the factors that we anticipated would be important drivers of smoking were absent in the data obtained from this research these include the tobacco industrys marketing 78 and smoking cessation campaigns which we hypothesized as potential influences but were not mentioned by participants as risk or protective factors of their smoking behaviors respectively a few themes that emerged in the study were not accounted for in the framework these included health consciousness for others such as family members and pets routine behaviors and environmental cues a few themes reported among tge individuals resemble at the surface factors that have been previously described in the general population including stress social influences routines and environmental cues although these factors are not unique to tge individuals the contexts and frequency of experiencing these factors may differ meaningfully between the tge and nontge populations for instance the underlying structural discrimination of tge populations may mean that they experience greater economic stress and financial difficulties 6 than nontge populations which in turn widens the disparity in smoking behavior among tge populations the issue of the social determinants impacting tge populations and their linkage with their experience of stress was highlighted by some participants in our study future research exploring the similarities or differences in risk and protective factors between tge and nontge populations will help to address questions about the contexts of experiencing these factors there were several lessons learned from the use of the digital photovoice approach within closed social media groups a few participants reported during the member checking discussion that being in the study provided peer support and they appreciated being in a group that understood their experiences as tge persons some participants described how the action of uploading a photo daily related to their smoking behavior helped them to keep track of their smoking use and they became more aware of the motivations to smoke participants reported that the groups provided a safe space that allowed them to connect and communicate with other participants who had similar experiences for instance one participant commented that with these people i can do anything including try to quit smoking the study procedures were generally viewed as acceptable and not overly burdensome we note that this study was not designed as a smoking cessation intervention and participants did not intend to quit smoking at the outset of the study however feedback from the participants suggested that the use of social media peer groups may be a promising component of groupbased support and interventions to reduce smoking among tge populations compared with previous research that used different approaches the photovoice approach in this study has the advantage of obtaining rich and contextual visual data of experiences of smoking risks and protective factors in close to real time detailed exploration of a broad range of factors impacting smoking behaviors using the participants own words and the ability to combine multiple sources of data collected from the same participants over time and geographic areas limitations this study has a few limitations owing to the limited sample size of participants from racial and ethnic minority backgrounds tan et al jmir public health and surveillance xsl • fo renderx we were unable to fully explore whether experiences of multiple axes of discrimination by gender identity race and ethnicity intersect in experiences of risk and protective factors among tge individuals from multiple minority backgrounds efforts to increase enrollment of tge individuals from multiple minority backgrounds in future work will yield data to critically address research questions related to intersectionality among these individuals although this study yielded a comprehensive set of risk and protective factors the study data were not representative of the experiences of the broader tge population who smoke however this work will inform the design of future survey research among a larger national sample of tge participants to assess the frequency of encountering these smoking risk and protective factors and appropriate strategies to address these factors in reducing smoking among tge individuals this study relied on participants who were motivated and comfortable with documenting and sharing their experiences of smoking risk and protective situations in the form of photos to their group although we did not receive feedback from participants that this deterred their sharing of certain experiences we acknowledge that this limitation may mean that certain sensitive topics related to smoking specifically may have been omitted future research may include an approach in which participants can submit photos individually instead of within a group conclusions to summarize this study identified realworld risk and protective factors among tge individuals who smoke and collect rich visual representations and participants own words in labeling risk and protective factors the longterm goal of this research is to reduce disparities in tobacco use and related health disparities among the tge populations the lessons learned from this study approach and rich data will inform future communityengaged research for designing a culturally responsive intervention to address these factors with tge community members as coequal partners authors contributions aslt sb pkg and jp obtained the funding for the study eh sb bcf fakc and pkg contributed to the data collection and analysis aslt and pkg wrote the initial draft and all authors contributed to the revisions and approved the final manuscript aslt is responsible for the overall content of the guarantor conflicts of interest none declared ©andy sl tan priscilla k gazarian sabreen darwish elaine hanby bethany c farnham faith a koromacoker jennifer potter suha ballout originally published in jmir public health and surveillance 06102021 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 jmir public health and surveillance 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 multimedia appendix 1

background transgender and genderexpansive tge adults are twice as likely to smoke cigarettes than cisgender individuals there is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among tge adults objective this study aims to qualitatively examine the risk and protective factors of cigarette smoking among tge adults through realworld exemplarswe conducted a digital photovoice study among a purposeful sample of 47 tge adults aged ≥18 years and currently smoking in the united states march 2019april 2020 participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private facebook or instagram groups next we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group we analyzed participants photos captions and focus group transcripts and generated themes associated with smoking risk and protective factorswe identified 6 major themes of risk and protective factors of smoking among tge individuals experience of stress gender affirmation health consciousness social influences routine behaviors and environmental cues we describe and illustrate each theme using exemplar photos and quotesthe findings of this study will inform future communityengaged research to develop culturally tailored interventions to reduce smoking prevalence among tge individuals

introduction by the mid of january 2020 the chinese government had quarantined the city of wuhan and subsequently extended the measure to hubei province to contain the coronavirus infectious disease 2019 epidemic since that time there has been a progressive spread of the virus throughout the world with 24854140 reported infections and 838924 deaths attributed to covid19 by 30 august 2020 1 on 11 march 2020 the world health organization declared a state of pandemic quarantine was considered one of the most helpful measures in containing the infection most countries issued varying degrees of shelterinplace orders 2 and almost onethird of the global population has faced some form of quarantine 1 due to the covid19 outbreak in the last few months however there is evidence that undergoing quarantine can have detrimental effects on peoples psychological health 3 with anxiety anger insomnia and somatic symptoms mainly due to the loss of freedom the separation from loved ones uncertainty over the disease and shortage of everyday supplies to date there is some evidence showing the negative impact of the covid19 pandemic on psychological wellbeing 4 5 6 one of the first surveys which was conducted in china during the lockdown showed that more than 50 of participants rated the psychological impact of covid19related restrictions as moderate or severe 7 with greater difficulties associated with the effects of covid19 pandemic on daily life and social and work activities 8 9 10 of course this negative impact is even greater for healthcare professionals tackling this global crisis 11 with a considerable proportion of workers reporting symptoms of depression anxiety and stress 12 the negative psychological effects of the covid19 pandemic on the individuals mental health states were further confirmed in studies from several western countries 13 14 15 as covid19 continues to spread so does the research on peoples experience of fear during the pandemic fear of personal infection or infecting loved ones is common among people exposed to any infectious disease outbreak 310 and it is worth carrying out a specific examination of the characteristics of the fear of covid19 globally more than 72 million people have contracted the virus infection and 16 million have died thus it is likely that the high mortality rates due to covid19 have negatively impacted on the individuals feelings of fear of contagion and anxiety throughout all countries of the world in the current study we will focus on a crosscountry examination of the covid19 outbreak and on the fear of covid19 by differentiating between european countries that reported a powerful impact of the infection and those that reported a mild impact during the first wave of the pandemic more specifically during the time lag of the current study there has been a reported cumulative 199414 infected and 26977 deaths in italy and 213095 infected and 23822 deaths in spain in only the time of the online survey they both witnessed over 10000 deaths these numbers are higher than those that were officially reported in croatia slovenia serbia slovakia and bosnia and herzegovina both italy and spain have applied emergency epidemiological measures first quarantine and then total lockdown the other countries covered by this research adopted mild restrictions ie the introduction of a state of emergency with curfew the introduction of a state of emergency without curfew and the closure of public life given the aforementioned differences not only in numbers of citizens infecteddeceased but also in the naturetype of epidemiological emergency measures the investigation of differences regarding the negative consequences of the covid19 pandemic seems worthwhile although fear is an adaptive response in the presence of danger it has been suggested that the construct of fear of covid19 should be examined within an integrated complex model 16 for example fear of infection can trigger healthy behaviors or on the contrary prompt anxiety about health concerns and fears about ones own health and the wellbeing of ones own beloved ones can exacerbate feelings of anxiety if these concerns are prolonged over time they may increase the risk of serious mental health conditions including anxiety disorders stress and traumarelated disorders 17 moreover feelings of uncertainty about the future and the lack of an effective vaccine may have led people to heighten their fear of covid19 during quarantine to date some new tools for the assessment of the fear of covid19 have been developed 18 19 20 to provide healthcare professionals with a valid measure for monitoring fear and anxiety of individuals during the covid19 crisis 1821 previous research showed a significant association between the fear of covid19 and the most widelyrecommended strategies to control the spread of covid19 such as spatial distancing and handwashing 2223 people with an excessive fear of the infectious outbreak are more likely to report greater psychosocial distress whereas people showing little anxiety are more likely to disregard the physical distancing 2024 an important step towards understanding the critical characteristics of this construct is to examine the crosscountry similarities and differences in fear of covid19 although there is some evidence to suggest that fear of covid19 may be concentrated in those regions with the highest reported covid19 cases 25 there has been limited research as to whether fear may differ in those european populations subjected to a high or limited impact of the infection and to policies of strict restriction moreover the association between fear of covid19 and social isolation during the lockdown needs to be further investigated in crosscultural research to date the link between peoples experience of fear of covid19 and feelings of loneliness has received little research attention although physical distancing measures have been critical in containing the rate of infection there is concern that limits on social activities and restrictions on inperson social contacts may increase feelings of loneliness 2627 prior research on the experience of loneliness in response to the social restrictions due to the covid19related quarantine reported mixed findings for example it was shown that being under a stayathome order was associated with greater loneliness and health anxiety however the higher perceived impact of covid19 on participants daily life was significantly associated with higher perceived social support and lower loneliness 14 moreover a recent longitudinal study 27 showed that although people perceived an increased absence of social connections during the initial stages of the covid19 outbreak they did not feel more isolated in response to the implementation of social distancing measures to the best of our knowledge no previous research has examined the link between fear of covid19 and feelings of loneliness during the lockdown transversely across countries it is likely that lockdown measures have resulted in worsening individuals sense of loneliness and fear of covid19 although some studies showed that individuals who felt lonely in the pandemic reported symptoms of anxiety and depression 1328 and that greater emotion regulation difficulties and depression may be risk factors for loneliness 29 interplay remains unknown between feelings of loneliness and fear of covid19 in countries facing varying levels of the spread of infection as well as different homeconfinement policies the present study examines individuals experience of fear of covid19 and loneliness in response to physical distancing and restriction measures undertaken to contain the outbreak of covid19 in different countries more specifically this study aims to examine potential crosscountry differences in the measures of fear of covid19 and loneliness across two groups of european countries subject to varying impact of the covid19 pandemic we hypothesize that fear of covid would be associated with loneliness during the pandemic and can represent top stressors moreover in line with prior studies 1328 we expected that countries reporting a high death and infection rate would display a higher fear of covid19 associated with feelings of loneliness compared to countries reporting a low infection and death rate in the midst of the pandemic we also aim to examine gender and age group differences across countries we do expect gender differences in fear of covid19 and loneliness and it was hypothesized that females would report more fear of covid19 and would feel lonelier than males in accordance with previous research 2729 finally we expected that the elderly would feel lonelier and would also display greater fear of covid19 than the young in all countries 613 materials and methods participants and data collection the sample consisted of 3876 participants from 7 european countries whose ages ranged between 18 and 82 years the majority of participants described themselves as female 1422 described themselves as male and 12 described themselves as other gender however given the very low number in this grouping in the current study we limited data analyses to men and women recruitment of participants was designed as an online survey with a general invitation to participate participants could respond ie choose to participate without receiving incentives from the point of view of sampling within the consortium of the 7 countries that conducted the study the first target group was students of faculties of the consortium and then their wider social networks participants were invited to participate in the survey with personal transmission of the questionnaire via individual eaddresses databases and posting the link to the questionnaire on social networks official webpages of partners organizations and local online newspapers participants completed a 22item online survey everyday life practice in covid19 time during the restriction time for covid19 pandemic from 15 april 2020 to 28 april 2020 30 participants had to be 18 years or older and living in the european countries indicated they were categorized into four age groups emerging adults young adults middleaged adults and older adults however due to the covid19related restrictions and the limited recruitment window we were able to conduct a nonprobability sample all materials and procedures were reviewed and approved by the consortium of six partners from science and research centre koper slovenia faculties of sport at university of novi sad serbia university of palermo italy university of zagreb croatia university of presov slovakia and university of cadiz spain the study was conducted in accordance with the ethical standards of the declaration of helsinki and all participants signed statements of informed consent to participate in this study the ethics committee of the university of novi sad approved this study prior to data collection each institution of the participating countries agreed to move forward with the study under the institutional review board approval of the university of novi sad participants were informed that all data would have been processed and managed by the legislation for the protection of personal data and the general data protection regulation they were able to leave the questionnaire at any stage before the submission process only surveys with completed mandatory questions were taken for further analysis measures the survey was made up of sociodemographic questions the fear of covid19 scale 18 and the threeitem loneliness scale 31 the questionnaires were translated and backtranslated to ensure that the wording was appropriate for spain bosnia and herzegovina croatia serbia slovakia and slovenia the study was conducted in line with some recommendations by swami and barron 32 to ensure semantic equivalence in the first step the original questionnaire was translated into the target languages by two mother tongue translators each translator produced an independent translation and all participated to a synthesis meeting for back translation two separate native englishspeaking translators independently translated the synthesized version of the target questionnaire into english the forward and back translations were reviewed by a research committee with language professionals and methodologists in order to make final semantic adjustments and produce the final version of the measure fear of covid19 scale participants completed the fear of covid19 scale by ahorsu et al 18 which consists of 7 items with answers on a 5point scale from completely disagree to agree it was constructed considering existing scales on fears expert evaluations and interviews and it shows very good psychometric properties specifically it shows stable psychometric properties across countries with a good reliability threeitem loneliness scale loneliness was measured by the 3item loneliness scale by hughes et al 31 it consists of three items determining lack of companionship the feeling of being left out and the feeling of being isolated from others measured on the frequency hardly ever some of the time and often for the purposes of the present study the items were treated as three different indicators of feelings of loneliness data analysis descriptive statistics of the total result for the fear of covid19 scale and items from the threeitem loneliness scale were calculated on the total sample and subgroups regarding gender age and country correlational analysis through pearsons r was performed to see whether loneliness items and fear of covid19 were interrelated countries were divided into two groups with specifically the most endangered italy and spain in one group and slovenia croatia serbia slovakia and bosnia and herzegovina in the other group establishing significant multivariate differences of two or more groups was tackled by discriminant analysis 3334 subsequently the canonical multigroup discriminant analysis of groups defined by age gender and country was carried out on the total result of the fear of covid19 scale and items from the threeitem loneliness scale by using the discriminant function analysis procedure described by jennrich 35 in statistica the results of multivariate and multiplegroup discriminant analysis are the number of significant discriminant functions the identification of variables defining each discriminant function and the mapping of the groups in the space defined by discriminant functions 36 the significance of the first and subsequent discriminant functions was tested by wilks lambda values at the level of statistical significance p 001 standardized discriminant coefficients and correlations of independent and discriminant variables were determined the means for the discriminant functions by group were computed centroids were represented in threedimensional cartesian space results preliminary results descriptive statistics are summarized in supplement tables s1 ands2 twelve participants who identified as being in the other gender category were excluded therefore the total sample size was n 3864 for further testing on the fear of covid19 and the loneliness scales fear of covid19 and loneliness items were significantly correlated at p 001 independent variables distributions are significantly different from the norm because of skewness but this should not invalidate the discriminant analysis 3738 discriminant analysis canonical discriminant analysis of groups defined by age gender and country for the fear of covid19 and the threeitem loneliness scale resulted in three significant discriminant functions whose discriminant coefficients are represented in table 2 the first discriminant function is predominantly defined by the result of fear of covid19 feeling that the lack of companionship contributes to a lesser extent the second discriminant function is mainly defined by feeling isolated from others and the tendency to feel the lack of companionship more the third discriminant function is determined by feeling left out partial contributions of two further measures of loneliness are also detected but to a much lesser extent regarding the negative side of the first discriminant function described mainly by the lower level of fear of covid19 three centroids of groups lie in less endangered countries the results of males from c1 countries are either negative or nearzero values rising from the youngest group upwards the centroids of female groups from c1 countries also show that fear increases with age compared with males female centroids are shifted to higher values and only the youngest group centroid is positioned on the negative side of the function all the centroids of groups from italy and spain on the first discriminant function are on the positive side of the function they do not show the same regularity as groups from less endangered countries the first three age groups of males have lower values then corresponding female groups but the eldest males have the highest centroid value on the first function the emergingadult female group has the lowest value whereas the highest value is in the young adult female group the centroids of groups from less endangered countries on the second discriminant function show that females feel isolated from others more often and feel the lack of companionship more than males three female groups from italy and spain have nearzero values and only the young adult female group has centroid on the negative side of function males from the first three age groups have centroids on the positive side of the function and the eldest male group has the centroid on the negative side of the function the third discriminant function is defined by the feeling of being left out in the groups from less endangered countries only elderly males and middleaged females have centroids on the positive side of the function the others have nearzero values seven groups from italy and spain have nearzero or centroids on the negative side of the function only the group of middleaged males felt they were being left out more often discussion the present study examined crosscountry differences concerning the fear of covid19 and loneliness due to the varying degrees of outbreak severity our results suggest that the centroids of female groups from c1 countries also show that fear increases with age compared with males female centroids are shifted to higher values and only the youngest group centroid is positioned on the negative side of the function all the centroids of groups from italy and spain on the first discriminant function are on the positive side of the function they do not show the same regularity as groups from less endangered countries the first three age groups of males have lower values then corresponding female groups but the eldest males have the highest centroid value on the first function the emergingadult female group has the lowest value whereas the highest value is in the young adult female group the centroids of groups from less endangered countries on the second discriminant function show that females feel isolated from others more often and feel the lack of companionship more than males three female groups from italy and spain have nearzero values and only the young adult female group has centroid on the negative side of function males from the first three age groups have centroids on the positive side of the function and the eldest male group has the centroid on the negative side of the function the third discriminant function is defined by the feeling of being left out in the groups from less endangered countries only elderly males and middleaged females have centroids on the positive side of the function the others have nearzero values seven groups from italy and spain have nearzero or centroids on the negative side of the function only the group of middleaged males felt they were being left out more often discussion the present study examined crosscountry differences concerning the fear of covid19 and loneliness due to the varying degrees of outbreak severity our results suggest that both males and females in european countries in april 2020 suffering from a powerful impact of the covid19 pandemic reported higher fear of covid19 and sense of loneliness than those in countries with a lesser spread of the virus consistent to our hypotheses it is likely that the higher number of infections and deaths in the first months of the first wave of the pandemic and the strict shelterinplace orders in italy and spain could have fostered heightened levels of fear of covid19 and feelings of loneliness moreover from the analyses it resulted that people who had a high level of fear of covid19 tended to suffer loneliness to a lesser extent and those feeling more isolated also tended to feel the lack of companionship however discriminant analysis showed that this pattern of results should be examined in more detail by considering the different age and gender groups as expected from the analysis of the centroids in countries with low death rates and mild social restrictions both the emerging adults and young adults did not show a high level of fear but felt the lack of companionship especially in the case of men at the same time middleaged and older women showed a higher level of fear and lower lack of companionship conversely people from high death rate countries and harsh restrictions experienced a higher fear of covid19 without feeling the lack of companionship furthermore middleaged men and young adult women felt both the lack of companionship and being left out these results are not surprising if we consider that during the timelag of the survey italy and spain underwent strict restrictions and lockdown which could have impacted on the peoples sense of loneliness moreover italy and spain registered over 10000 deaths in the two weeks of the survey alone while bosnia and herzegovina slovenia slovakia and serbia had 160 deaths in total furthermore previous data from the usa also showed that fear appeared to be concentrated in regions with the highest reported covid19 cases 25 regarding the influence of gender our results confirmed that women reported greater fear than men both in c1 and c2 countries this finding is consistent with literature showing that females may be more vulnerable to developing psychosocial distress during the pandemic 68 research on the impact of covid19 pandemic on mens and womens wellbeing treated separately is still scarce and there is a need to tackle gender equality in any decision making for the covid19 39 the findings of the current study suggest that the discriminant functions can be used to identify subgroups at high risk of distress during the covid19 pandemic the elderly females from countries with low death rate could be considered a group at moderate risk of excessive fear of covid19 and lack of companionship given the mild restrictions imposed in these countries this vulnerable group could be supported by regular exercising and maintaining a healthy diet pattern to help prevent symptoms of stress during the pandemic of note in italy and spain older men represent a class of individuals at risk of a high fear of covid19 and feelings of social isolation from a policymaking perspective more attention should be paid to these vulnerable groups by enhancing online health services and support moreover these vulnerable groups should be helped in avoiding potentially false reports and continually checking covid19 related news in order to alleviate their feelings of fear and anxiety the covid19 outbreak is likely to worsen the individuals perception of loneliness by reducing social interactions and contacts 29 given that loneliness is a risk to physical and mental health there has been a call for a public health framework to tackle loneliness during covid19 especially in older adults 4041 our results showed that the older male group in italy and spain felt isolated from others and felt the lack of companionship more often they also reported a higher fear of covid19 than other age groups thus they may be identified as a subgroup at high risk of social distress during the covid19 pandemic 40 overall the results of this study which was conducted during the first wave of the covid19 pandemic indicate multiple correlations between fear of covid19 and feelings of loneliness with sociodemographic characteristics of individuals on the one hand and epidemiological emergency measures at the state level on the other therefore they point to the need for more detailed research with a focus on gender generation or socioeconomic groups for example a crosscohort study from the uk reported that young adults people with a lower education and income and people living alone had a higher risk of being lonely 42 further research is necessary to examine whether the accumulation of multiple risk factors can impact on loneliness levels across different european countries physicians could help lonely adults to use social services and communitybased organizations and support them in alleviating loneliness and addressing essential needs 43 our results showed that females in c1 countries felt isolated from others and with a lack of companionship more often than males it could be speculated that in countries with mild social restrictions following the covid19 outbreak women were more fully engaged with demanding family activities than men and had less opportunities for social interactions thus feeling lonelier at this difficult time strengths and limitations of the study the main strength of the current study is that we examined the impact of the coviddifferent european countries this study also has several limitations first the study relies on crosssectional data which were collected during the first wave of the pandemic further research is needed to examine how the levels of fear of covid19 and loneliness changed over time second limitations of the study exist in terms of the selfselective nature of participation in this online study furthermore the recruiting per country resulted as unbalanced there is evidence that disadvantages of online and single wave approach are a low control over the sample and response rates from low to modest which can result in an unbalanced structure of the sample 44 45 46 further research is necessary to replicate these findings with balanced and representative samples of the general population moreover welleducated people are more likely to participate in an online survey than the lesseducated as confirmed by smith 47 and people of a low socioeconomic status might not be provided with the internet and it technology third the fear of covid19 represents a novel construct and the importance and validity of this variable remains unknown 16 moreover the fear of covid19 scale was not fully validated for some of the languages used in the current study and further research is warranted to test its crosscountry measurement invariance finally due to the demands of social desirability using selfreport measures may not reflect peoples real opinions and feelings 47 conclusions overall our results show that people from european countries with a high number of infections and deaths during the covid19 pandemic reported different levels of fear and feelings of loneliness than people from countries with very low death and infection rates our findings support calls for the countries involved to monitor over time the longterm effects of the covid19 pandemic on the individuals levels of fear and loneliness given the rise of infections and deaths in the second half of 2020 moreover our results highlight the fact that future research on the negative health consequences of the covid19 pandemic should examine different age and gender groups separately in order to assess which groups might be more vulnerable and consequently to take actions to help those at most risk analysis of emotional wellbeing in groups at risk may help to lessen the long term social and economic costs due to the covid19 outbreak and integrate behavioral health expertise into public health responses to the pandemic 48 49 50 future research on the negative health consequences of the pandemic can build on the crosscountry studies that adopted the fear of covid scale in several european countries such as italy spain israel norway and russia 51 52 53 54 55 which have consistently supported the importance of assessing the fear of covid as a relevant clinical outcome among the general population in order to assist decisionmakers and health practitioners to screen the most vulnerable groups

the aim of the current study is to examine gender age and crosscountry differences in fear of covid19 and sense of loneliness during the lockdown by comparing people from those countries with a high rate of infections and deaths eg spain and italy and from countries with a mild spread of infection eg croatia serbia slovakia slovenia and bosnia and herzegovina a total of 3876 participants 63 female completed an online survey on everyday life practices in covid19 time in april 2020 including measures of fear of covid19 and loneliness males and females of all age groups in countries suffering from the powerful impact of the covid19 pandemic reported greater fear of covid19 and sense of loneliness in less endangered countries females and the elderly reported more symptoms than males and the young in spanish and italian samples the pattern of differences is considerably more complex future research should thoroughly examine different age and gender groups the analysis of emotional wellbeing in groups at risk of mental health issues may help to lessen the long term social and economic costs due to the covid19 outbreak

a introduction national education is a goal to be achieved by the state taking into account sociocultural psychological economic and political aspects the education is aimed at forming a special characteristic or national character with a national personality along with the rapid development of human life in the era of globalization there are also various educational problems surrounding sociocultural life this is because the schools where formal education takes place for the younger generation have not been able to unite in a planned directed integrated systematic and sustainable movement with social life social sciences is tasked with developing the potential of students so that they have sensitivity to social problems that occur in society have a positive attitude to correct all inequalities and are skilled in overcoming every problem that occurs daily both those that befall themselves and in society changes in social life that are so fast provide several problems that occur in society this is because there is no mental readiness to accept each of these changes in indramayu regency itself social problems that often occur are brawls binge drinking promiscuity labor problems and drug abuse dependence on narcotics can cause physical and mental health problems and can even cause death as creatures who have common sense humans should avoid narcotics abuse in their lives the problem caused by the development of narcotics abuse is an educational problem because by providing proper education about the dangers of narcotics students will be saved from narcotics abuse the fact is that most drug users start abusing narcotics at school age this is where the role of social studies learning can contribute to the dangers of narcotics for the world of education along with the rapid increase in narcotics users in indonesia it means that almost every place in this country has the potential for abuse of narcotics users and dealers including the younger generation and people of various ages in response to this parents teachers and the community should be aware of the development of narcotics abuse from the social service of indramayu regency data on rehabilitation efforts were obtained for category x narcotics users namely users who have stopped using narcotics most of which are students who have dropped out the rehabilitation efforts are carried out in stages according to the quota obtained by the social service every year starting from this phenomenon it is necessary to take steps so that education in schools can equip students with the introduction of the dangers of narcotics in an effort to prevent and overcome the development of narcotics culture in society especially among students education especially social studies is expected to provide the abilities abilities and skills needed by students to avoid even getting out of narcotics in order to live a better life based on the main ideas and limitations in the background of the research that has been described the focus of this research is why narcotics abuse occurs as a form of social deviance in indramayu regency in general this study aims to examine and observe the implementation of social studies learning in the socialization of narcotics culture which has been declared an enemy to society the nation and the state so that students have the ability to avoid and have the courage to get out of the dangers of narcotics then proactively and creatively seek and find solutions to overcome them b method this research was carried out using a qualitative paradigm with a case study research method because social research cannot always be generalized as in exact sciences this is due to differences in research subjects specifically this study aims to describe and understand the problems that occur among drug abusers the rules that apply in their community in certain situations including their relationships activities attitudes and views this research tries to put aside all prejudices and tries to find out as much information as possible including the expression of feelings and expectations of the informants the social problem chosen as the theme of this research is a social reality that requires understanding so that in collecting data direct interviews and observations were carried out to seek this understanding the qualitative research paradigm holds that social reality cannot be separated from the thoughts and perceptions of the subject data is collected from various sources to reveal an indepth picture of the case being observed to explore eventsevents that have passed within a certain time data collection is carried out in depth from various sources of information the sampling technique used in this study to determine the informants is purposive sampling namely the technique of determining the sample of informants who will be the data source with certain considerations in qualitative research the selected sample serves to obtain maximum information not to generalize interviews with basic informants and other supporting informants as representatives of the community namely related parties from the social service police district narcotics agency and correctional institutions also with research subjects in this case the victims of narcotics abuse in the selected research locations interviews were conducted to obtain accurate data regarding their knowledge of narcotics itself their socioeconomic background to provide solutions for the problems they are currently facing and so on so that rolling will occur like a snowball in accordance with the methods and characteristics of qualitative research the main research instrument is the researcher himself assisted by an open interview guide the researcher acts as a human instrument which acts as a planner determining the focus of research implementing collecting data analyzing interpreting data finally reporting the results of the study in carrying out activities in the field researchers usefield notes thus it is hoped that the collected data has a sufficiently convincing level of confidence so that the research results obtained meet the requirements for qualitative research the data collection technique is the most strategic step because the purpose of this research is to obtain data through observation interviews and documentation studies which are then compared with the administration of social studies learning the level of credibility of any information obtained must be justified from the source of the information qualitative data analysis is carried out continuously until the data is saturated researchers do not look for data to prove the truth or reject hypotheses made previously but make abstractions when specific facts are collected and grouped together the stages of carrying out the research are all activities carried out sequentially from the beginning to the end of the research which will provide an overview of the overall planning implementation data collection analysis and interpretation of data to writing reports on the handling of narcotics abuse as a social deviant in indramayu regency c results and discussion profile of indramayu regency indramayu regency stretches along the north coast of java which is also an intercity transportation route known as pantura with an area of 204011 hectares and a coastline of 1141 km indramayu regency stretches from cirebon to subang having a large area and not far from the capital city of jakarta this area becomes a target for the distribution of narcotics most of the access to narcotics circulation that occurs in indramayu regency is through land transportation the high rate of population growth without being matched by quality improvements has caused indramayu regency to be prone to narcotics abuse the age group with the largest number of residents of indramayu regency is in the school age range this is where extra efforts are needed considering that all respondents admitted that they started abusing drugs at school age and continued into adulthood the level of public education which is still relatively low requires the government to work hard in increasing understanding especially for the younger generation in order to suppress the level of social deviation in society in sociocultural life apart from the level of education there are several other indicators that determine the success of development namely health income level family planning and religion in this study the five main indicators will be described in greater depth because they play a major role in dealing with narcotics problems the culture that grows and develops in indramayu regency is a form of implementation of the expression of the local community which is influenced by javanese and sundanese culture so that the form of culture is an acculturation of the two cultures nowadays it is very difficult to find the purity of meaning from art and culture which is a tradition of the people of indramayu regency on the one hand the development of art and culture that continues to develop is influenced by foreign elements that are difficult to avoid on the other hand performing arts and cultural events in various activities is always accompanied by the use of alcohol which can open up opportunities for narcotics to enter this drunken behavior has become a habit that is difficult to get rid of so that it often causes public unrest and results in other social problems this is also reinforced by data from several respondents who come from an adequate economy class narcotics abuse in the community of indramayu regency 1 background on narcotics abuse in indramayu regency indramayu socially is a diverse area as a migrant area indramayu is very multicultural there are many tribes living in indramayu regency such as sundanese javanese palembang batak padang even to makassar and banjar there are also others in the field of education the graduation rate of students from primary and secondary schools has increased even to 100 in the economic sector peoples income levels also increased as a result of the opening of the pertamina up vi balongan oil refinery and many people became workers abroad in terms of culture many people especially teenagers easily absorb influences from outside cultures as can be seen from the changes in lifestyle caused by the diversity of the community along with the increase in local revenue the people of indramayu regency make them have a consumptive lifestyle although the level of education is increasing there are still many people who are not fully aware of the importance of education as can be seen from the minimal number of students who continue their education to a higher level as a transit area many people in indramayu regency work outside the area such as jakarta and other cities in addition there are many migrant workers who go back and forth as tkw interaction with various groups of people who are not healthy is one of the triggers for social deviations from narcotics abuse due to association between adolescents and lack of supervision from parents in 2009 there were 30 cases of narcotics abuse with 61 suspects and in 2010 there were 20 cases of narcotics abuse with 43 suspects thats just data obtained from one agency namely the police from the data revealed cases that were caught in the act not yet cases of narcotics victims who were not tracked by the police from a geographical point of view indramayu regency is a golden triangle that is prone to narcotics smuggling in addition to land access the north coast route is also a traffic bridge for transporting people and narcotics goods especially if there is no equipment and adequate monitoring and supervision personnel the population growth of indramayu which is quite high with the number of young people depicted in the expansive pyramid is a potential market for the illicit marketing of narcotics high levels of unemployment and poverty cause life pressures to be heavier and can plunge people into drug abuse to eliminate problems ironically the illicit trafficking of narcotics is seen as an opportunity to earn a living for his family the decline in morality faith legal awareness and weak social supervision of the community are situations and conditions that are vulnerable to abuse and illicit trafficking of narcotics in fact not all of the people of indramayu are ready to accept all the changes caused by globalization the process of rapid social change high industrialization has now penetrated into indramayu regency with the construction of the pertamina balongan processing unit and several other small and medium business factories bringing sociocultural changes globally both positive effects by increasing pad and reducing unemployment also a negative influence characterized by an excessively consumptive lifestyle where drug abuse is a part and a place of escape all narcotics users are shortsighted due to ignorance such as is who admits that he does not understand the negative consequences of further ill effects of narcotics he just thought there must be pleasure for the person who wears it furthermore ad also thought if it doesnt taste good why sell it the following are the reasons fordrug abuse a external reasons the results of the study show that many narcotics users come from families that are not harmonious only a small number of cases come from wellestablished families both in terms of economy and education relations between family members are cold even tense or hostile poor communication between father mother and child often creates endless conflicts conflict in the family can encourage family members to feel frustrated so they are trapped to choose narcotics as a solution usually the most vulnerable to stress are children this bad situation finally drags children into the grip of narcotics that are already around them due to environmental influences that are supported by global conditions such as demographics education economy and socioculture around them case 1 the child feels less affection and attention in the family feels annoyed disappointed and lonely this happened to mj his parents have good social status but because they are busy with their respective work matters the child does not get full attention so that he is carried away by the association of peers who drag him into narcotics luckily mj can still be saved with rehabilitation efforts and good religious education meanwhile yl who is materially well off but lives without being accompanied by her parents only lives with her grandparents every day causing her to become more and more familiar with narcotics and the life of promiscuity among todays young people case 2 the child feels less appreciated lacks trust and is always considered wrong this happened to cm one of the former users who had received treatment and rehabilitation he has a large family with eight siblings b internal reason • curiosity the feeling of curiosity is usually owned by the younger generation at the age of elementary school junior high school and senior high school if in front of a group of young people there is someone who demonstrates the enjoyment of consuming narcotics then driven by the natural instinct of his young soul namely curiosity then one of the others in the group will come forward to try it apart from being driven by curiosity his courage was also driven by the turmoil in his soul who wanted to be considered great brave so one child fell into the clutches of narcotics in conditions like this the reactions of their peers are different this is what happened to several groups of children in indramayu at the age of sn mj and is there are those who want to know then follow suit some want to look great and bold some are loyal friends then they use it the feeling of being loyal to friends is indeed very strong for the younger generation if it doesnt get a positive channel it can be dangerous and will become negative attitudes like that cause children to follow suit at first he only smoked marijuana once in turn then each of them started wanting to enjoy themselves so that they became a group of marijuana users after all using marijuana increasing to methamphetamine and so on • feelings of disappointment frustration and upset feelings of annoyance disappointment or frustration can happen to anyone usually occurs because of failure in the younger generation this happened to ik and yl they become narcotics users because for a moment they can forget the disappointment annoyance and frustration yl has a bad relationship caused by a failure to communicate with her parents who are rarely home and receive little attention causing feelings of resentment that lead to drug use in addition feelings of disappointment due to the failure of a friends or boyfriends relationship in the past have also plunged him into the arms of narcotics young people also have a strong drive for exploration and adventure in life including sex and drug abuse likewise the urge to enjoy the happiness of life its different with ik who is frustrated with his life as a farmers son always lacking and unable to control his desire to follow a consumptive lifestyle causing him to fall into the clutches of narcotics young people have a strong urge to follow trends and modern lifestyles the use of narcotics is seen as part or a feature of that modern lifestyle this makes youth very vulnerable to drug abuse • fear of experiencing pain one of the regular users is ww he becomes compact because he is not strong or feels pain when he does not use it because he was afraid to feel the suffering he continued to use narcotics so that he became a loyal user this also causes him to play a dual role as a dealer so that he can continue to enjoy marijuana without having to spend money on the contrary he can get money from every transaction until finally caught redhanded and had time to languish in a correctional institution after making several observations observing more closely while holding direct interviews with several people who have or are still using narcotics it was concluded that there are several reasons why someone can use narcotics especially in indramayu regency namely to be happy easily influenced by friends high curiosity to get new experiences seek sensations join friends for fear of being ridiculed not macho sissy and so on due to group solidarity fear of getting pressure from group members wanting to appear brave and prominent eliminating boredom and stress rebelling against the circumstances and realities of life that he is experiencing and also the availability of narcotics c anticipation efforts on narcotics abuse from the indramayu regency government based on data obtained from the police resort indramayu regency narcotics cases that have been handled in 20092010 there are about 50 cases all of them are p21 there needs to be cooperation between the authorities and the community the basic information that is really needed is where they get the narcotics and how they are distributed this is intended to break the narcotics distribution network especially in the indramayu regency which has become a work goal to be achieved so far the efforts made by the police in dealing with narcotics abuse cases both for users and dealers have been good repressive action by taking action against producers dealers narcotics dealers as well as users who offer to other people is based on the applicable laws and regulations however sometimes they also take preventive measures such as counseling about narcotics to schools usually at the time of new student admissions information obtained from the social service of indramayu regency that every year indramayu regency gets a quota to send users and those who have stopped being narcotics users to rehabilitation centers but in different amounts for example in 2010 only six of the 14 people sent were classified as category x narcotics users namely those who only became victims of narcotics abuse and did not play a dual role as dealers in addition the social service has indeed coordinated with all subdistricts to collect data on each village and subdistrict of the presence of narcotics users and former users and disseminated the rehabilitation program as an effort to deal with it there are several difficulties that become obstacles in carrying out rehabilitation for these narcotics users and former users namely the difficulty of gathering rehabilitation participants there are also some of the victims who still remember their past such as longing to try again until they leave their dormitory they did not finish their training because they had only arrived for less than two months and they ran away without notice efforts to get out of narcotics addiction according to information obtained from the district police indramayu that in the indramayu regency the types of narcotics and narcotic precursors that are commonly found in circulation and misused are marijuana and shabushabu both are included in the category i narcotics category these two types of narcotics are widely used because of their relatively affordable prices from the observations that have been made and according to several informants there are several places commonly used for narcotics abuse activities includingempty boarding houses or dormitories riverbanks and empty yards crossroads bus terminals and train stations dimly lit stalls in this study it can be observed that generally narcotics users are made aware by their parents although with a little coercion there are also those who are made aware of by their peers who were originally both drug users the measures used also vary some were sent by village officials for rehabilitation some were invited by their friends some took a spiritual approach which certainly played a big role in healing efforts namely the parents of the narcotics users the seven users who received rehabilitation measures and have now started a new drugfree life if other people have not been able to awaken users there are other provisions that have been regulated in the narcotics law namely legal sanctions this is intended to cut off the circulation of narcotics that can damage the joints of the life of the nation and state especially in the lives of the younger generation this is what happened with ww for more or less he was struggling with narcotics abuse and even had a double role as a dealer as well the impact of narcotics abuse that is very striking is the change in lifestyle and the erosion of ethics among adolescents namely the development of behavior that is not in accordance with the values and norms in society in general for users who have been categorized as addictsaddicts they look like they have lost their will to live life in the future in general the perpetrators of drug abuse see that the future for them is not an important thing social studies learning the role of social studies education in providing an understanding of the dangers of narcotics abuse seeing the reality of the increasing development of narcotics abuse in indramayu regency education in schools is obliged to take part in its prevention efforts from the data obtained so far learning at the secondary school level does not emphasize the impact of narcotics abuse this can be seen by the large number of users each year for this reason it is necessary to have comprehensive prevention efforts and the active role of not only teachers and students but also communication and collaboration with parents and the community to prevent themselves from the narcotics problem formally prevention efforts can be carried out in the classroom according to the existing curriculum so far the teacher has not played a maximum role in providing an explanation of the dangers of narcotics abuse to students in the social studies curriculum in junior high school the social deviation material provided by the teacher is only discussed in general terms does not develop in depth about examples of deviations what are the dangers for students and the social environment and how to anticipate them this is where the teachers role must be optimized in conducting social studies learning so that it can provide students with an understanding of social deviations caused by narcotics abuse by providing guidance from an early age on awareness and understanding of the proper use of drugs also by adding interesting and useful physical and mental activities and teaching them how to develop communication skills to resist peer pressure for the secondary education level teachers began to develop clear policies on narcotics issues especially starting to emphasize sanctions for narcotics users and dealers namely by socializing law no 35 of 2009 on narcotics from the results of interviews with government agencies it is recommended to provide an explanation of this narcotics law in every secondary school to prevent social problems due to drug abuse apart from providing information about the types of narcotics that are widely circulated and their impact on themselves and society it is hoped that they will place more emphasis on legal sanctions to give emphasis on students so that they are afraid and will not try them so far the obstacle in efforts to handle narcotics abuse which is most commonly found in narcotics abuse cases in indramayu regency is the lack of initial understanding about narcotics what are the types and how it affects their next life another thing is the lack of ability to be able to stop the habit of abusing narcotics generally they are afraid to be separated from the drugs they are used to and the desire to try again is very strong meanwhile what is very helpful in efforts to deal with narcotics abuse is that it is no longer considered taboo to talk about social problems around free life in the community so that we can choose which information can be used to socialize narcotics to students us according to the level of understanding in their age in social science education at the junior high school level there are basic competencies that explain social deviant behavior in society one of the main topics of discussion is social problems caused by narcotics abuse in addition the current governments role in efforts to eradicate narcotics abuse is very large considering the many negative impacts it will have on the future growth of the younger generation as the nations next generation prevention of narcotics abuse must be carried out in an integrated manner because it is a complex problem caused by three factors namely individual factors environmentalsocial factors and the availability of narcotics itself indicating that prevention of narcotics abuse must be carried out effectively using a comprehensive and integrated approach at school at home and in the community as a social science education teacher the most basic and effective coping methods are promotive and preventive actions the promotive program is a coaching program aimed at students who have not used narcotics or are not even familiar with narcotics the principle is to increase student activities significantly so that they never think about obtaining pseudohappiness by using narcotics his introduction to the narcotics problem was only a cursory warning while preventive is a prevention program aimed at students who are still healthy and do not know narcotics in order to know the ins and outs of narcotics so they are not interested in abusing them in addition to providing cognitive understanding social studies teachers are also expected to be able to develop affective learning in students by instilling attitudes that are in accordance with learning objectives as a debriefing various skills can be developed for students through selfdevelopment activities by carrying out a stricter and more intensive monitoring system and establishing good communication with parents it is hoped that this narcotics abuse prevention effort can run optimally realizing that the problem of narcotics abuse can not only be tackled through the eradication of illicit narcotics trafficking it is necessary to develop a balanced approach between law enforcement and prevention by realizing also that the problem of narcotics is a very complex problem caused by various factors effective prevention is to tackle the problem of narcotics abuse in an integrated integrated directed planned and sustainable way for this reason it is considered necessary to elaborate social science learning with values education especially by taking sources from social values that exist in society internalization of social studies values to integrate the value learning process into social science learning is not an easy thing apart from the readiness of students to fully understand themselves and their environment the problems that arise must be truly understood the value education process can only occur if the theories andor principles regarding this matter are understood and applied from the planning activities of the learning program until the end of the learning process the success of the process and results of value education learning activities depend on the clarity of the target of moral values expectations that must be personalized and the clarity of teaching materials as well as the reliability and affordability of the learning media apart from the teachers skills in packaging the content of the message and how it looks in front of the class teachers must also use varied and communicative methods so that the target of moralvalue expectations in accordance with the content of the message demanded in the learning can be achieved for this reason the selected learning material must be related to its environment if coaching about these values is carried out as early as possible gradually sequentially and continuously the goals of affective learning will produce satisfactory results value education is an educational program and process that emphasizes the development of affective aspects where the scope of this value education involves fostering the value system of the students themselves the development of this value education is partly because cognitive education is often not consciously prepared and implemented to develop this value system so that learning often takes place very low in appreciation of the values contained in something that is being studied this condition results in students in learning social sciences not having the competence to be able to carry out a choice of values as the basis for behaving as good citizens because the value system that a person believes will have a very strong influence on his behavior and personality value education is certainly closely related to personality education while the ultimate goal of social studies learning is to shape the personality of the students so it is appropriate that social studies teachers in carrying out the learning process should provide students with an understanding of narcotics abuse by prioritizing value education so it is very important as social science teachers we are able to package the process of learning activities by looking for sources that are full of values especially values formed from each individual and family as part of society based on the description above this research tries to elaborate value education with social science education regardless of how many values exist in our society by observing the conditions that occur in society in indramayu regency researchers try to find the meaning of the missing values and try to bring them back into social studies learning at school to get value educationbased social learning researchers try to develop learning tools by looking for learning resources that occur in society these sources will be packaged into value competencies to be achieved which are the ultimate goal in social studies learning while the model chosen is to use a value analysis approach that helps students learn to make decisions through systematic process steps the methods that can be used in learning this model are individual or group learning about social problems that contain moral values field investigations and class discussions the value competencies that must be achieved from cases of social deviation caused by drug abuse behavior include discipline rational thinking responsibility selfrespect working in groups controlling emotions having knowledge independent learning skills healthy living skills communication decision making problem solving to obtain social studies learning that can improve students understanding both cognitively affectively and psychomotorically a structured and systematic learning process is needed researchers have designed this learning from the beginning of planning to evaluating one competency standard according to the curriculum namely social deviation with the topic of narcotics abuse before carrying out the learning process 25 questions are given in category c2 to measure the extent to which students understand the behavior of narcotics abuse why people can fall into these situations how to avoid and overcome them and what impacts will be caused for their social environment all questions that will be given are based on facts that occur in the field after the researchers conducted observations and interviews with several sources who became informants both users former users and dealers from these experiences the questions are made and packaged in the form of multiple choice with four options the distribution of the level of difficulty is carried out with a percentage of 16 easy with four questions 50 moderate with 12 items and 34 difficult with 9 items so that the total number of questions is 25 items troubleshooting value 24 the value of making decisions 25 source sk and kd for junior high school after launching a number of questions to the students the researcher analyzed the items by grouping students into two groups namely the upper group and the lower group this is intended to find out whether the question is feasible or not given to students during the learning process to be carried out namely by looking for the distinguishing power and level of difficulty of the questions of understanding planning social studies learning in making a lesson plan the first thing that must be in place is the learning objective learning objectives must be clear and measurable that is they must state what students will learn as a result of the lesson and are ordered from the simplest to the most complex learning objectives are obtained from clear competency standards and basic competencies and have been included as references the social studies learning plan that is made must include competency standards basic competencies the chosen topic theme namely narcotics abuse indicators made according to the theme learning objectives character values to be instilled main material implementing social studies learning the strategy used is problem based learning which presents various problems surrounding narcotics abuse so that it can reveal the causative factors and how to overcome them the methods used include discussion literature review role playing and lectures in this study the steps of learning systematically will be described starting from the initial activity content and closing completed with the assessment evaluating learning in evaluating learning researchers use learning outcomes assessment for the category of civics and personality subject groups the assessment is divided into two namely process assessment and result assessment process assessment is taken at every meeting in carrying out learning activities in the form of tasks performance bills attitudes and so on meanwhile the assessment of the results is taken from the post test every time you complete a competency standard in this case you have completed the materials related to that competency social studies learning with competency standards to understand the problem of social deviation and the topic of narcotics abuse conducts process assessments with performance techniques that are taken directly from observations in each implementation of learning activities in addition the results were also assessed when conducting the post test using a written technique the form of the instrument used was multiple choice with the same questions when the researcher did the pre test this is intended to determine the extent to which the level of students understanding of the teaching materials in these competencies after the learning process is carried out it can be seen that the success rate of teaching and learning activities can provide students with an understanding of narcotics abuse which can cause various social problems in society with high categories education can be interpreted as a process of changing behavior so that they become adult humans who are able to live independently and as members of society in the surrounding natural environment of course this does not only include intellectual development but also emphasizes the process of developing ones personality this is in accordance with the objectives in social studies learning namely to shape the personality of the students of course it is not an easy thing the situation of the development of narcotics in indramayu regency is motivated by various factors in the social life of the community which are so complex both externally and internally namely the geographical and demographic conditions of the population who are vulnerable to the distribution of narcotics items of methamphetamine and marijuana types the situation of sociocultural changes and modernization that have not occurred in tandem with the development of narcotics by improving the quality of public education the cause of delinquent behavior in adolescents stems from families who have less role in this case parenting patterns that affect their deviative social structure group pressures wrong roles and social status such things are cultural and social factors that greatly influence individuals in defining themselves lack of communication with family can be the main cause for teenagers to become drug abusers every child who interacts with his social environment will have an influence on the formation of his personality to overcome the various problems that arise from the behavior of these drug abuse users it takes a strong determination from within those who have already fallen into the grip of narcotics as well as full support both morally and materially from the family and the community around where they live because if only waiting for the desire to stop and repent from the users is very difficult to do it has been confirmed in law no 35 regarding narcotics article 53 paragraph 1 doctor is allowed to provide treatment to patients with narcotics abuse based on medical indications of narcotics group ii or group iii in limited quantities and in certain preparations in addition rehabilitation opportunities are also provided for users as stated in article 54 namely narcotics addicts and victims of narcotics abuse who are required to undergo medical rehabilitation and social rehabilitation appointed by the government to receive treatment andor treatment through medical rehabilitation and social rehabilitation socialization about the dangers of narcotics abuse is indeed very important considering that many youths participate in abusing it because they do not know about the dangers of narcotics even until they become abusers they are not yet aware of the failure and decline in their quality of self that they have experienced so far as a result of narcotics abuse by paying attention to the above it is appropriate that social studies education must be able to socialize the dangers caused by narcotics abuse to avoid the emergence of more complex social problems considering that social studies is tasked with developing the potential of students so that they have sensitivity to social problems that occur in society has a positive mental attitude to correct all inequalities and is skilled in overcoming every problem that occurs daily both those that befall himself and those that occur in society this goal can be achieved when social studies learning programs in schools are well organized according to gross the large number of social sciences included in social studies education make it a learning about human relations with other natural environments as well as helping students develop competencies and attitudes to become citizens in a free society using materials from various social sciences to understand social problems in addition hasan also clarifies in his book social science education that the objectives of social science education are grouped into three categories namely the intellectual development of students the development of abilities and sense of responsibility as members of society and the nation and the development of students self as individuals the first goal is oriented to the development of intellectual abilities related to the students self and the interests of science the second goal is oriented to the development of students self and the interests of society while the third goal is more oriented to the personal development of students both for the benefit of themselves society and science realizing that the problem of narcotics abuse is a very complex problem caused by various factors effective prevention is the prevention of narcotics abuse in an integrated directed planned and sustainable manner so as not to cause social deviations in society while the way that is considered appropriate is through the learning process at school where students are directed and invited to communicate directly about various social deviations caused by this drug abuse behavior in addition by integrating narcotics abuse material into the competency standards of social deviations in junior high schools it can provide an increase in understanding with good results because analytically there is an increase in student understanding from before and after learning in the cognitively high category with increasing student knowledge morals values by building positive attitudes and characters in students as well as changing behavior as a manifestation of both d conclusion based on the results of the research that has been done it can be concluded that drug abuse in indramayu regency is caused by many factors in addition to internal and external factors related to users drug abuse in indramyu regency is also influenced by regional conditions geographically demographically and socioculturally in dealing with drug abuse all efforts made by the government will not be optimal if it is not balanced with the users personal efforts in general there seems to be a desire from users to stop but most of them fall back into the trap when they see an opportunity to abuse drugs therefore one of the efforts that can improve the ability of the younger generation to prevent drug abuse is through learning activities in schools with the integration of the discussion material and a systematic process it can be seen that there is an increase in students understanding of the material of social deviation due to narcotics abuse menangkal narkoba dan kekerasan jakarta balai pustaka ischak su et al references

this research is motivated by several facts about the morality of social phenomena occurred in indramayu regency namely the increasing abuse of narcotics among the people of indramayu especially students one way to anticipate these problems is through efforts to prevent narcotics abuse by disseminating the impacts of social studies learning this research uses case study method data collection techniques were carried out by means of interviews documentation studies and direct observation to the main data sources and supporting data sources which were integrated into the social sciences curriculum for junior high school namely the social deviance competency standard with cases of narcotics abuse to determine the extent to which the social studies learning process could improve students understanding of abuse narcotics the social impact it causes and how to avoid it the results of this study describe 1 the causes of narcotics abuse that become social deviant behavior in indramayu regency namely the environmental conditions around the users such as geographic demographic and sociocultural factors as well as external and internal reasons from within the narcotics users namely family friends curiosity and frustration 2 efforts made by users to get out of the bondage of narcotics types of marijuana and methamphetamine such as wishes to recover and rehabilitation efforts organized by the victims family as well as related agencies which are very helpful for users 3 integration narcotics abuse material into the competency standards of social deviation in junior high school which provides an increase in understanding before and after learning significantly better with the results of high category analysis cognitively with increasing student knowledge morallyvalues build positive attitudes and characters in themselves resulting from the learning process as well as behavior change as a manifestation of both

coronavirus disease 2019 covid19 is a pandemic disease 1 transmitted from human to human 2 caused by the severe acute respiratory syndrome coronavirus 2 that emerged in late 2019 in wuhan mainland china 3 4 5 covid19 can have a severe to fatal course primarily in elderly populations 6 but it also affects children 7 and young adults 8 in which the clinical course has been described to be mild or even asymptomatic 9 physical interventions such as social distancing 1011 wearing face masks 12 and implementing strict hygiene measures 13 reduce the rate of infection by reducing the transfer of respiratory viruses from infectious to susceptible persons through contact droplets or aerosols 14 these interventions not only lower the chance of infection but also quantitatively reduce the viral inoculum received by the recipient 1516 and may change the route of transmission 17 from direct droplet transmission in close proximity to the infecting person 18 to indirect transmission via contaminated surfaces 19 higher nasal viral load is associated with worse clinical outcomes for severe acute respiratory syndrome 220 and higher initial viral exposure is associated with more severe disease 21 to our knowledge it is unknown if lowering the viral inoculum during infection with sarscov2 or altering the mode of infection by physical means can affect the clinical course of the disease here we present an outbreak at a swiss army base with 2 very similar groups infected prior and after the implementation of stringent social distancing and hygiene measures while both groups showed evidence of infection the rate of symptomatic covid19 among the infected soldiers differed significantly between the 2 groups and was much lower in the cohort where infection occurred after the implementation of these measures we provide evidence that sdhms not only are effective in reducing transmission but also can alter the clinical course of covid19 in infected individuals we hypothesized that the difference in the clinical presentation of infected persons might be due to lower viral inoculum during infection or an altered mode of transmission of the virus but further studies are needed to answer this question methods we recruited soldiers stationed at a swiss army base in airolo between 25 march and 14 april 2020 patients not feeling fit for service were required to report to our clinic and were promptly isolated and tested for covid19 by nasopharyngeal swabs additionally asymptomatic soldiers were sampled crosssectionally as indicated in figure 1 nasopharyngeal swabs as well as serum samples were taken simultaneously data collection as well as clinical followup ceased on 3 may 2020 reverse transcriptasequantitative polymerase chain reaction in triplicate for sarscov2 targets was performed on all nasopharyngeal swab samples detailed descriptions of sample collection and rtqpcr can be found in the supplementary appendix and supplementary figure 1 the immune response against sarscov2 was measured by commercial enzymelinked immunosorbent assay kits used according to the manufacturers instructions kits from epitope diagnostics inc were used to measure immunoglobulin m and igg titers kits from euroimmun were used to measure iga titers serological data normalization and validation are described in the supplementary appendix data were analyzed with r statistical software version 361 specificity and sensitivity analyses were calculated using epi version 240 this study was approved by the ethical commission of the republic and canton of ticino all procedures involving human participants were conducted in accordance with the ethical standards of the declaration of helsinki and its amendments written informed consent was obtained from every included patient and participant in their native language after oral education study participation was voluntary and not enforced by any means results we observed a covid19 outbreak at a swiss army base in airolo three companies were stationed at the base while companies 2 and 3 shared the same barracks and their soldiers had abundant contact with each other sharing the same kitchen and communal areas company 1 was based at barracks separated from the other 2 companies by a distance of approximately 3 km and 200 m of elevation minimal contact occurred between company 1 and the other companies the demographic characteristics of all 3 companies were similar with a median age of 204 years due to a stringent recruitment process soldiers with severe healthrelated constraints are generally excluded from military service company 1 consisted exclusively of male soldiers while 12 of companies 2 and 3 were women some of the soldiers instructors and other personnel at the base were stationed in separate units and therefore grouped as other they were excluded from further analysis due to group heterogeneity and segmentation into various subgroups with a very low sample size each on 11 march 2020 we diagnosed the first patient suffering from covid19 in company 3 we refer to this date as day 1 a epidemic curve of patients with covid19 as a fraction of the total population of the 3 companies while company 1 organizationally and spatially separated from the others had no case of covid19 companies 2 and 3 show a very similar course where onethird of the population were symptomatic for covid19 b symptomatic cases of covid19 and rate of infection among the 3 companies the rate of infected persons was significantly smaller in company 1 than in the other companies and was determined on day 34 by combined nasopharyngeal swab and serological testing a person was considered infected if either returned a positive result the fraction of symptomatic patients among the infected was significantly larger in companies 2 and 3 than in company 1 abbreviations covid19 coronavirus disease 2019 sarscov2 severe acute respiratory syndrome coronavirus 2 of the outbreak in the following weeks we observed an epidemic in companies 2 and 3 as depicted in figure 1a while company 1 had no cases on day 9 it became clear that the disease was widely spreading within companies 2 and 3 both units were put under quarantine and hygiene measures were rigidly enforced across all 3 companies soldiers had to keep a distance of at least 2 m from each other at all times and in situations where this could not be avoided they had to wear a surgical face mask a distance of 2 m was enforced between the beds and during meals all sanitary facilities were cleaned and disinfected twice daily symptomatic soldiers were immediately separated and required to report to our clinic where they were tested for covid19 using nasopharyngeal swabs strict separation of the unaffected company 1 from the other companies was enforced until data censoring on day 54 29 of companies 2 and 3 suffered from rtqpcrconfirmed symptomatic covid19 none of the 154 soldiers from company 1 was diagnosed with covid19 all soldiers with symptoms compatible with a respiratory infection or who did not feel fit for service were required to present at our clinic additionally symptoms as well as vital parameters were assessed daily in the unaffected company 1 it is thus unlikely that we missed a symptomatic case of covid19 we tested 15 symptomatic soldiers from company 1 for covid19 all were negative on day 35 of the outbreak we crosssectionally sampled 363 asymptomatic soldiers of all 3 companies as well as other units on the army base by nasopharyngeal swabs serological testing and a systematic questionnaire of the 88 tested soldiers of the unaffected company 1 we found evidence of active or past exposure to sarscov2 in 13 soldiers 7 produced a positive nasopharyngeal swab and 7 exhibited evidence of a sarscov2specific immunological response in the affected cohort we found evidence of exposure to sarscov2 in 64 of company 2 and 59 of company 3 206 and 372 tested positive by rtqpcr and 592 and 667 had a positive serology none of the soldiers tested on that day presented symptomatically in our clinic or showed symptoms in our daily assessments during the following 19 days of followup despite daily assessment viral concentrations were lower than in symptomatic patients but still detectable since 29 of the soldiers of companies 2 and 3 had previously presented with symptoms of covid19 more than 30 of this population must have been infected asymptomatically but still developed a detectable immune response infection in these soldiers is likely to have occurred after the implementation of sdhms given that these measures were implemented 25 days prior to the testing date the fraction of symptomatic patients with covid19 among all soldiers with evidence of exposure to sarscov2 either by rtqpcr or serology was significantly lower in company 1 than in companies 2 and 3 companies 2 and 3 not only had an increased rate of infection but soldiers in these companies also had a higher probability of developing covid19 when infected more than 50 of the soldiers of all companies could be sampled however 36 of company 1 and 42 of companies 2 and 3 either refused to participate or were not available our sample is likely to be representative of all companies since we sampled a high proportion of the population and we are not aware of any possible selection bias possibly introduced by the nonparticipants thus the reported fractions of infected likely represent the true prevalence within the cohorts to exclude an ongoing infection in company 1 prior to the implementation of sdhm we tested 23 asymptomatic soldiers by nasopharyngeal swabs and serology on day 20thus 11 days after implementation of these measures none had a serological response and no viral rna was detected in their nasopharyngeal swabs excluding an infection of more than 122 of company 1 at day 20 with a confidence level of 95 at that day although the sample of 23 patients was not drawn randomly a relevant bias most likely was not introduced by the selection process hence infection in company 1 most likely occurred after day 20 and thus after implementation of sdhms while both companies 2 and 3 had cases of covid19 prior to this date at the end of the exponential growth phase of the epidemic on day 14 of the outbreak we used nasopharyngeal swabs and serology to sample a group of 41 asymptomatic soldiers in the heavily affected company 3 by rtqpcr 20 tested positive for sarscov2 and 3 tested positive by serology over the following weeks we followed up on these soldiers and registered 6 symptomatic covid19 cases in this population five had been negative by nasopharyngeal rtqpcr for sarscov2 during our sampling while only one had had a borderline positive result without a quantifiable virus load the remaining 19 soldiers who tested positive for sarscov2 by nasopharyngeal swab on that day never developed covid19 and remained asymptomatic nasopharyngeal virus quantities were comparable to those of symptomatic patients suggesting similar infectivity we treated more than 100 young previously healthy adult patients with covid19 at our clinic all were treated symptomatically no patient died was admitted to the intensive care unit or needed mechanical ventilation one patient was referred to a hospital with interstitial pneumonia requiring oxygen supplementation for 4 days but recovered without obvious sequelae despite the high reported prevalence of thromboembolic 2 flowchart of the study a total of 354 soldiers of companies 2 and 3 were spatially and organizationally separated from 154 soldiers of company 1 on 11 march the first case of covid19 was diagnosed in the left cohort thus infection in this group must have occurred prior to or on this date on 20 march strict social and hygiene measures were implemented in both cohorts on 31 march 23 asymptomatic soldiers from company 1 were tested of whom all showed negative serology and pcr on 14 april we conducted a crosssectional testing on all soldiers who agreed to take part in our study from company 1 88 soldiers were tested 13 were positive by pcr or by serology of 181 asymptomatic soldiers from companies 2 and 3 113 were positive by either serology or pcr we continued to follow up both cohorts for 19 more days none of the tested soldiers developed covid19 during this time while in companies 2 and 3 102 cases of covid19 were diagnosed company 1 remained without cases this finding infers a profound impact of social distancing and stringent hygiene measures on the outbreak of covid19 in an infected cohort while companies 2 and 3 were infected prior to the enforcement of such methods nearly onethird of all soldiers developed covid19 and a high level of seroconversion was observed the cohort to the right was infected after 31 march and thus after the enforcement of social distancing and hygiene measures despite 15 asymptomatically infected soldiers in company 1 on 14 april we did not observe a single case of covid19 in this cohort this demonstrates that enforcing social distancing before infection can lead to milder clinical courses of covid complications among severely ill patients with covid19 8 we observed no thromboembolic complications in our population although pharmacological thrombosis prophylaxis was only used in 1 case however mechanical thrombosis prophylaxis was applied by encouraging physical training and involvement in cleaning and disinfection measures discussion we describe an outbreak of sarscov2 infections in young healthy soldiers in 2 spatially separated groups with almost identical baseline characteristics but different clinical courses while 1 cohort was heavily affected by covid19 with 102 cases of 354 soldiers the separated group was infected later and had no case of covid19 in a total of 154 soldiers until the censoring of data despite a liberal testing strategy stringent sdhms were enforced in all companies 9 days after the first case of covid19 was diagnosed both companies 2 and 3 had cases of covid19 prior to implementation of these measures however the unaffected company 1 was infected with sarscov2 after implementation of social distancing between days 20 and 34 of the outbreak as evidenced by nasopharyngeal colonization or immunization in 13 asymptomatic soldiers several asymptomatically infected cases were identified in all groups while 40 of the infected cases in companies 2 and 3 developed covid19 none of the 13 infected cases in company 1 suffered from covid19 strict enforcement of sdhms prior to infection therefore reduced the rate of covid19 among those infected since we followed up the soldiers for 19 days after testing and soldiers were required to immediately report to our clinic if they became symptomatic during this period we can exclude that any of the soldiers tested on that day later developed symptoms 99 of cases become symptomatic before day 14 after infection 22 while sdhms reduce the reproductive number 2324 these nonpharmacological interventions have to our knowledge not been known to reduce the fraction of patients who fall ill of covid19 among those who are infected prior to this study although all 3 companies were very similar demographically all members of the unaffected company 1 were male soldiers but approximately 10 of the affected companies 2 and 3 were female a key role for gender in the spread of the disease is unlikely as other studies have reported no differences in viral shedding between males and females 25 the literature on the ratio of asymptomatic infections is controversial ranging from 4 of a highly selected and exposed group in shanghai 26 18 on the diamond princess cruise ship 27 to up to 75 2829 in crosssectional studies some even reporting clusters of entirely asymptomatic cases 30 this large range of the rate of symptomatic covid19 among infected individuals might reflect the differential implementation of measures to prevent exposure to the virus or the mode of infection as observed between the 2 groups reported in this study companies 2 and 3 showed high infection rates approaching the proposed level of herd immunity of 70 31 in company 1 infection occured after the implementation of sdhms and the rate of infected individuals remained significantly lower the epidemic might have ceased not only due to the implementation of sdhms but also due to herd immunity since both factors effectively lower the reproductive numbers of the virus social distancing and hygiene measures have been shown to quantitatively reduce the viral inoculum during infection 1516 the route of transmission might also be changed by sdhms 17 from direct droplet transmission in close proximity to the infecting person 18 to indirect transmission via contaminated surfaces 19 although the hygiene measures implemented involved regular disinfection of potentially contaminated surfaces our data show that sdhms not only slow infection with sarscov2 but also can attenuate the clinical course by reducing the rate of symptomatic patients among those infected these findings suggest that reducing the viral inoculum might not only lead to a reduced probability of infection but also could favor an asymptomatic infection while still being able to induce an immunological response at least in a proportion of the infected however our study did not directly explore the effect of viral inoculum on the clinical course of an infection with sarscov2 but shows the profound effect that sdhms have thereon since our study population consisted of young predominantly male adults our findings might not be applicable to the general population studies involving more heterogeneous populations under similar physical separation measures currently show a seroprevalence of 69 among 2049yearolds 32 which is much higher than what is expected based on covid19 case numbers it remains to be clarified if asymptomatic infection protects from future reinfection and thus if herd immunity can be induced via asymptomatic infections before a vaccine is broadly available supplementary data supplementary materials are available at clinical infectious diseases online consisting of data provided by the authors to benefit the reader the posted materials are not copyedited and are the sole responsibility of the authors so questions or comments should be addressed to the corresponding author notes

background social distancing and stringent hygiene seem to be effective in reducing the number of transmitted virus particles and therefore the infectivity of coronavirus disease 2019 covid19 and could alter the mode of transmission of the disease however it is not known if such practices can change the clinical course in infected individuals methods we prospectively studied an outbreak of covid19 in switzerland among a population of 508 predominantly male soldiers with a median age of 21 years we followed the number of infections in 2 spatially separated cohorts with almost identical baseline characteristics with severe acute respiratory syndrome coronavirus 2 sarscov2 before and after implementation of stringent social distancing results of the 354 soldiers infected prior to the implementation of social distancing 30 fell ill from covid19 while no soldier in a group of 154 in which infections appeared after implementation of social distancing developed covid19 despite the detection of viral rna in the nasal and virusspecific antibodies within this group conclusions social distancing not only can slow the spread of sarscov2 in a cohort of young healthy adults but it can also prevent the outbreak of covid19 while still inducing an immune response and colonizing nasal passages viral inoculum during infection or mode of transmission may be a key factor determining the clinical course of covid19

introduction adolescence is the age stage after childhood ends adolescence is a period of searching for identity and a period of transition from childhood to adulthood adolescence from the latin word is adolensence which means to grow or grow into adulthood grow here is not only in the physical dimension of adolescents but also in the context of intellectual psychosocial selfesteem intimacy and others the term adolescence has a broader mean which includes mental emotional social and physical maturity at this age adolescents are faced with changes that occur to them changes that are expected to occur in adolescents are of course changes in a positive direction considering that youth are assets of the state as the younger generation who will continue the ideals of the nation lead and govern the country teenagers as the next generation of the nation should get a good education so that they have the ability to continue the nations noble ideals however to realize youth as a virtuous generation is not easy various challenges must be faced by adolescents to complete their developmental tasks in adolescence the existence of developmental tasks for adolescents can make adolescents feel complex problems within themselves as stated by sofia that the physical growth of adolescence will be followed by turmoil and problems both medically and psychosocially this turmoil and problems can be caused by the condition of adolescents who are looking for identity against new norms that apply in their environment besides that teenagers are also susceptible to being influenced by foreign cultures such as japanese culture japan is known for its popular culture through manga or japanese comics anime or japanese cartoons japanese popular culture has succeeded in attracting public attention currently it is also very popular and in great demand among indonesian teenagers so at the same time the presence of fujoshi and fudanshi teenagers is a form of the popularity of japanese culture in indonesia fujoshi or rotten girl can be interpreted as a broken woman and a rotten girl while male fans of this story are known as fudanshi be told damaged and rotten because women are considered to like something that deviates from the habits of women in general and from social values in society fujoshi and fudanshi have a penchant for homosexual love stories changes in behavior or characteristics of homosexual individuals include adolescents become closed to their surroundings addicted to homosexual content apathetic and emotional based on research ghassani the changes that occur in adolescents as connoisseurs of homosexual love stories are as follows fujoshi and fudanshi cannot regard objects such as bananas cucumbers even ice candles as something normal anymore because these objects are identical to the shape of the male reproductive organ the way they see the men around them changes first the fujoshi will divide the men around her into seme and uke groups seme is derived from the japanese verb semeru and uke from the verb ukeru both terms refer to the position during sex whether in an attack position or a receive position obrien further explained that uke means bottom or bottom which indicates the position when sexual intercourse is carried out while seme means top then imagine what would happen if the men were paired as homosexual couples if they saw two gay men they would instantly guess between seme or uke becomes easily irritated if you cannot find bl yaoi manga in bookstores because you are forced to search among nonyaoi manga this is due to their aversion or boredom towards heterosexual genre manga easily aroused due to sex scenes in yaoi manga and anime to note in the yaoi anime if there is a scene of seme and uke having sex the sound when they do it is also played at the beginning of its appearance this story was produced through manga however with the ease of access to the internet today the spread of japanese culture is spread through films dramas anime and manga so that the production is easier for teenagers to reach medan city as a metropolitan city has become an entry point for the spread of japanese culture based on an initial survey conducted by researchers as many as 57 fujoshi and fudanshi youths in medan city joined the whatsapp social media group the existence of fujoshi and fudanshi teenagers as a negative impact of the ease of internet access among adolescents in the city of medan apart from being a medium of information and communication the use of the internet has also changed its function to become a medium of entertainment for teenagers in the city of medan where teenagers can see thousands of homosexual contents both actors in filmsseries and actual homosexual actors from the results of preliminary observations conducted by researchers there were 7 fujoshi and 3 fudanshi with an age range of 1220 years in bandar selamat village based on the results of observations made on fujoshi and fudanshi teenagers in bandar selamat village the changes that occur in adolescents who are fans of homoerotic stories include teenagers spending more time alone in the room the emergence of addiction to accessing homosexual pornography excessive anxiety when someone borrows their smartphone accompanied by the desire of teenagers to have samesex relationships and inner turmoil to change their gender besides that fantasies arise when they see friendly relations between men in the real world therefore efforts are needed by parents to overcome adolescents through the application of family functions family functions include religion socioculture love protection reproduction socialization and education economy and environmental development the purpose of this study was to describe the existence of fujoshi and fudanshi youth in bandar selamat village and to find out the application of family functions in dealing with fujoshi and fudanshi teenagers in bandar selamat village the benefit of this research for adolescents is to make their lives more directed according to the norms and values prevailing in society for parents it is useful as input and material for consideration in making policies in order to overcome the deviant behavior of fujoshi and fudanshi hobbies in adolescents for the community developing community knowledge regarding parents efforts to prevent youth from following fujoshi and fudanshi hobbies method this research was conducted using a descriptive research method with a qualitative approach a qualitative approach is a study aimed at describing and analyzing phenomena events social activities attitudes thoughts of people individually and in groups the qualitative approach was chosen because it is considered appropriate to find out the application of family functions carried out by parents in dealing with adolescents who like homosexual love stories in bandar selamat village medan city this research was carried out for 2 months from april to june 2022 in the bandar selamat village medan city the subjects in this study were two families who had taken steps to deal with teenage fans of homosexual stories while the object of research is the application of family functions in tackling teenage fans of homosexual love stories the author uses the technique of taking informants by purposive sampling m rifqih child 3 fitri a mdak mother family b 4 arisa child on table 1 both families were selected as respondents in this study on the grounds that both families had teenage fujoshi or fudanshi children based on their characteristics namely selfclosure addiction to homosexual content apathy and emotional as teenagers who enjoy homosexual love stories parents have taken steps to overcome their teenage childrens penchant for consumed homosexual love stories through the implementation of family functions the procedures in this study were grouped into three stages include the orientation stage to obtain an overview of the problem to determine the research fo cus the exploratory stage collecting data and the checking stage to check the validity of the data data collection techniques were through observation interviews and documentation by observed the application of family functions in overcoming the teenage characters of fujoshi and fudanshi as fans of homosexual stories namely selfclosure addiction to homosexual content apathy and emotion qualitative data analysis techniques in this study namely data reduction data presentation and drawing conclusions the validity of the data was obtained by carrying out a credibility test by carrying out observation persistence and data triangulation test the validity of the data is done through the credibility test dependability test and confirmability test result and discussion a the presence of fujoshi and fudanshi teenangers in bandar selamat based on the results of the study research data were obtained regarding the existence of fujoshi and fudanshi youth in this study there were four indicators to see the presence of fujoshi and fudanshi adolescents in bandar selamat village based on their characteristics namely selfclosure addiction to homosexual content apathetic and emotional 1 selfclosure fujoshi individuals will try to close themselves in front of their parents on the grounds that they do not want to be rejected by their existence in the family in social life fujoshi will cover their identities fujoshi are careful to control their personal information with certain people whose children are considered not to pose a threat to themselves and to refrain from behaving prominently in social interactions in this case teenagers are also very careful in provide information for themselves to maintain the confidentiality of their preferences both teenagers created second accounts to access and followed accounts of homosexual actors funbase accounts bl actors homosexual content creators and lgbt youtubers the second account allowed them to have more confidence in decidied what they should share with many people one day so that what they share in the first account is just an identity that has been packaged and planned as well as possible so that the public or general people see them according to what they are what they want not showing their own true side addiction to homoseksual content fujoshi and fudanshi teenagers are addicted to homosexual content so that teenagers access the latest homosexual content from drama to homosexual pornographic content so that ejaculatory activity in adolescents is out of control the more children are exposed to shows that contain pornography the more likely children are to engage in pornographic behavior viewing homosexual pornography in adolescents is no longer just a desire but is already at the stage of needing to consume homosexual pornography several studies have revealed that access pornography can improve mood however for teenagers who enjoy pornography it will usually have a bigger impact if it is done excessively according to dr mark b base on imawati d sari pornography can cause damage to five parts of the brain especially the part of the brain behind the forehead brain damage in this area will decrease academic performance in adolescents unable to make plans control their passions and emotions apathetic apathy is an individuals indifference when the individual has no interest and interest in certain aspects such as social life as well as physical and emotional aspects from the research results children are apathetic towards their social environment because they are very focused when them watched homosexual content in their room so that children can spend hours accessing homosexual stories on holidays children can access homosexual content all day to watch homosexual dramas when fujoshi teenagers are enjoying yaoi stories they become so focused on their yaoi for read that they lose track of time forget or become apathetic towards their surroundings the state of not being aware of their surrounded as experienced by the two children is also caused when teenagers see homosexual content teenagers lock their rooms and use earphones to enjoy watche teenagers often ignore people around of them because they feel engrossed in themselves and are enter into stories enjoyed of their fantasies emotional the emotions that occur when teenagers read homosexual stories teenagers will experience the same feelings as the characters in the story therefore teenagers can scream cry and laugh with joy when they seeread homosexual stories the e motional upheaval occurs in adolescents at one time this condition will also affect in dail y life when read an abnormal romance teenagers feel more excited and carried away by emotions than mainstream stories if fudanshi dont watch bl anime or read yaoi manga there is a different feeling so fudanshi will look for other alternatives to be able to access blyaoi content in another opinion teenagers also deliberately take the time to view various homosexual content adolescents who constantly consume homosexual content will be indifferent to their surroundings teenagers become very focused and can spend hours on end when fujoshi teenagers are enjoyed yaoi stories they become so focused on their yaoi read that they lost track of time forget or become apathetic towards their surroundings b implematation of family function dealing with fujoshi and fudanshi in kelurahan bandar selamat 1 dealing with child selfclosure a affection function the function of affection in the family environment is carried out by both families including 1 estabilsh interpersonal communication in the family interpersonal communication within the family aims to change childrens attitudes and behavior parents must maintain good communication with their children because maintain good communication shows that parents care about what their children are experience for fujoshi and fudanshi teenagers having a parent figure who can be a comfortable place for them is very necessary teenagers can complain to their parents and parents can help themselves in overcoming the bad habit of consumed homosexual films and know all the shortcomings felt by fujoshi and fudanshi teenagers so that parents and adolescents can work together in helping and encouraging children regardless of the habit of consuming homosexual stories 2 give attention and supervision the attention given by parents to supervise childrens activities on social media parents accompany their children when used smartphone also use the childs gmail account to the parents cellphone and carried out routine checks on the childs smartphone parents was supervise their children used smartphone are always check search history on their childs smartphone parents carried out supervision so that they can monitor childrens activities and remain in parental control the higher the level of parental monitoring of their teenage children the lower the possibility of deviant behavior befalling a teenager children who feel cared for and supervised by their parents will be more careful in their behavior b socialization and education function in the function of socialization and education parents play a role to help children to be able to interact with their social environment both in family school friends and the surrounded environment the function of socialization and education in the family as a place for parents to teach how to socialize is by develop interactions or relationships between family members to fulfill this function in developing childrens potential parents advise children to take part in learning activities outside of school 1 handling of addictive attitudes a religious function the function of religion places the family as the first place to instill religious values and give religious identity to every child born in dealing with teenage fans of homosexual love stories parents remind children of religious values that have been taught by parents and carry out worship in accordance with religious teachings parents who are able to carry out religious functions properly can increase positive changes in children because they follow in the footsteps of their parents as a whole in religion the functioning of religion that goes well in the family will strengthen the faith of every family member b protection function the function of the family as a shelter aims to foster a sense of security and peace as well as warmth for the family parents in providing protection for children from access homosexual content again the protection provided is as follows attitude protection in the form of a reprimand by parents to remind children about their wrong behavior when adolescents begin to show deviations parents as supervisors must remind adolescents of their mistakes and maintain the confidentiality of children from other family members so that children do not feel responsible parents are obliged to reprimand and remind children when children make mistakes because the warning has a great influence in opening childrens minds and encouraging them to change themselves for the better mental protection in the form of encouragement by parents for children to get rid of the habit of watched homosexual films and become better more ashamed individuals and still be able to establish communication with other family members c reproductive function the implementation of socialization and education functions was carried out by both families by giving directions to children to be free from accessing homosexual content directions are instructions to do something to do better in making changes directions given by parents and gift advice to children to use social media wisely children are asked to be responsible for everything they access guidance and direction to children is carried out in the form of giving advice by parents accompanied by words full of wisdom so that children change their attitudes and are able to refrain from addictive behavior accessing homosexual love stories children who are constantly being advised listen to positive things from their parents directions d socialization and education functions in this function parents teach and inform children about the dangers of access pornographic content according to cooper and mansson the higher the frequency a person accesses porn sites the more difficult it is for that person to control his sexual behavior this is because the materials on porn sites create sexual arousal making people more aggressive parents efforts in provide knowledge about the negative effects of addiction adult films to children are parents tried to keep their children away from homosexual content and explain sexual education to children c dealing with apathy child 1 religion function the implication of religious functions carried out by parents to overcome childrens apathy is carried out by givi advice to children that apart from worship human relations must also be carried out because worship to god alone is not said to be perfect if someone does not have a good relationship with others religion as a foundation in life directs individuals to behave in accordance with religious values giving religious advice to children encourages children to think and understand that as social beings they need other people in their lives 2 affection function in the application of the affection with carried out by parents to children so that children do not act apathetic towards family members is to give responsibility to children to look after their younger siblings when parents are working parents feel that when children are given the responsibility to look after each other it can form a childs sense of affection and concern for their younger siblings so that children can also interact with other family members parents create an intimate atmosphere with children to watch movies with children at home to establish interaction between parents and children as an effort to foster a sense of love and build a harmonious atmosphere at home this method is carried out by both families when they are not working this is done to further strengthen the affection between the family by watching movies together there will be familiarity between parents and children in addition parents can also monitor what shows their children watch 3 socialization and education function the application of socialization and education functions in both families is carried out by parents by maintaining communication parents who are busy working still must interact with their children in order to establish effective interpersonal communication in overcoming childrens apathy interpersonal communication has an important role in forming a good personality in children and giving positive influence from parents to children through effective interpersonal communication children will be able to interact within the family social environment form and maintain a meaningful social environment and change childrens attitudes apathetic d dealing with emotional child the ability to manage emotions is important for teenagers to learn considering that in this phase teenagers experience changes that make it difficult for them to control their emotions emotional management is carried out by parents through the application of socialization and education functions by means of which parents teach children to place their emotions in the right state sort out satisfaction be able to regulate moods and not get carried away in one emotion parents set an example for children to manage positive emotions that come out of every situation that occurs and to vent emotions with something that children like the way that parents teach their children helps regulate every emotion in their children and trains their children to have emotional intelligence there are 4 dimensions in distinguishing emotional intelligence namely understanding emotions using emotions to facilitate thoughts understanding emotional information regulating emotions parents have to teach regulated emotions children for helps children to socialize with their environment children become more mature and sociable individuals children can show up her felings regulate and manage their emotions can help themselves to adapt to various conditions the ability to regulate emotions is needed for children especially in their teens at this age children have a desire to be accepted by their peers by having good emotional regulation children can regulate negative emotions and behave in a way that is acceptable to their friends adolescents who have good emotional regulation can overcome feelings of sadness disappointment and despair so they can avoid the risk of depression in adolescents emotional regulation taught by parents to children encourages children to have maturity in emotional intelligence individuals who have good emotional intelligence are characterized by having mature social relationships making friends easily not easily afraid or anxious able to adapt to stress loads and have a great ability to inv olve themselves with people or problems to take responsibility and have perspectives moral conclusion the existence of fujoshi and fudanshi adolescents in bandar selamat village based on their characteristics are selfclosing children cover their identity as fujoshi and fudanshi to control personal identity by created second account 2

teenagers as fans of homosexual love stories are considered as a form of deviation that occurs teenagers hobbies violate religious and social values in society teenagers like things that are considered deviant as a result there is a change in adoles cent behavior adolescents become closed addicted to homosexual content apathetic and emotional the purpose of this study was to describe the existence of fujoshi and fudanshi adolescents based on their characteristics selfclosing addiction apathy and emotionality and to determine the application of family functions in tackling the character of fujoshi and fudanshi adolescents in bandar selamat village this research was conducted using a descriptive research method with a qualitative approach data collection in this qualitative research uses interactive techniques including participant observation interviews and documentation the data analysis technique is done by reducing the data displaying the data and drawing conclusions the validity of this research uses cre dibility dependability and confirmability tests the results showed a description of the existence of fujoshi and fudanshi teenagers based on their characteristics fujoshi and fudanshi teenagers who consume homosexual stories can be overcome by implementing family functions the application of family functions in dealing with fujoshi adolescents includes the application of the functions of religion love protection reproduction as well as socialization and education the five functions implemented by parents can overcome the behavior of children who are fans of homosexual love stories for this reason as parents they should be able to balance themselves with technological developments today so that they can monitor all childrens activities on social media

introduction in recent years the development of economy and medical care systems have largely expanded life expectancy however a longer life expectancy also made older adults suffer more from disability preventing disability can reduce huge healthcare expenditure hospitalization and mortality rates china has the largest population of older adults in the world and the country is aging much faster than other countries this may cause a large number of older adults to live with disabilities in 2020 more than 40 million chinese older adults were disabled and it was estimated that disabled older adults in china will reach 65 million by 2030 therefore more research into disability patterns and related determinants among older persons is required to develop more effective interventions to alleviate the financial burden of healthcare costs on families and society in the field of demography time can be captured by three temporal dimensions age period and cohort each aspect of apc makes a unique contribution to population health age is an indicator of biological processes that cause internal physiological changes and eventually lead to morbidity disability andor death period describes morbidity disability orand death at a given time and reflects economic sociocultural and technological aspects cohort captures the health status of successive generations who are born in a social system during a similar period of time and experience similar social experiences in their lifetime failure to distinguish apc trends may lead to a nonnegligible bias and provide an incomplete analysis of population health trends though many studies explored the trends in disability only a few studies explored the apc trends in disability among older adults the results consistently displayed an increasing age trend however the period and cohort trends were more equivocal lin et al found decreasing period and cohort trends for both blacks and whites among the oldestold in america by studying a crossclassified random effect model lin et al also found a decreasing period trend and an increasing cohort trend among people aged 70 years and over in america by performing a fixedeffects approach a study conducted in hong kong showed an increasing period trend of adl disability and no cohort effect among chinese older adults zhang indicated an increasing period trend and a declining cohort trend among the oldestold in china using the intrinsic estimator method however this study was focused on the oldestold which was too old to represent the older population in china the differences in cultural context age indicators of disability or methods used in the analysis may account for the inconsistent results of previous studies so further studies are needed to explore the apc trends in disability among chinese older adults the disablement process model proposed by verbrugge and jette in 1994 may help us to understand the process involved in disability according to the disablement process model disability defined as difficulties in the performance of socially defined roles and tasks is commonly measured by the activity of daily living and the instrumental activities of daily living and reflects the functional limitation in reallife contexts fl refers to a disability independent of the situational requirement recently more researchers recognized that fl may improve the evaluation of disability the disablement process model is widely used to explore the influencing factors of disability among older adults according to the disablement process model risk factors accommodating factors and disease could affect the disability process for instance risk factors contained demographic factors and health behaviors demographic factors included gender education and so on health behaviors contained smoking exercising and so on accommodating factors included social supports eg spouse living arrangement household income and social participation and so on disease included chronic disease and psychological resilience however few studies included these variables to explain the cohort and disability trends in disability especially using multiple indicators of disability the current study aimed to examine age and cohort trends in disability among chinese older adults and explore the disablement process factors that may explain the cohort trends in disability by analyzing survey data from five waves of the chinese longitudinal healthy longevity study methods study design and participants this study draws on data from five waves of clhls to ensure sample representativeness the clhls randomly selected 23 out of 31 provinces in china which covered 85 of the total population in china in the survey individuals aged 65 years and over were studied and the baseline number of participants in 2005 was 15638 survey details were provided in previous studies the multiple imputation method was efficient to handle mar missing values therefore this study applied the mi method to deal with the missing values of independent variables we also included alive dead or lost to followup as a categorical variable into the growth apc model to control for any bias due to these statuses dependent variables activity of daily living was measured at each wave using six items dressing bathing indoor transferring toileting continence and feeding participants were asked if they needed assistance with each of the six activities individuals were defined as having adl disability if they needed assistance in performing at least one of the six daily activities instrumental activities of daily living was composed of eight items shopping visiting neighbors washing clothes making food walking 1 km crouching and standing carrying 5 kg weight and taking public transport respondents were categorized as having iadl disability if they needed help in performing at least one of the eight items functional limitation was formed by five items standing up from sitting in a chair holding a hand behind the neck holding a hand behind the lowerback being able to pick up a book from the floor and holding up arms older adults unable to perform at least one of the five items were treated as having fl and were coded as 1 and those who were able to perform all the items were coded as 0 independent variables time variables age was taken as a continuous variable and included in the model after mean centralization to facilitate the interpretation of control variables disease disease included chronic disease and psychological resilience chronic disease was a count of selfreported health conditions including diabetes hypertension cancer arthritis respiratory diseases tuberculosis stroke cataract duodenal ulcer glaucoma bedsore and parkinsons disease psychological resilience was measured by three items including look on the bright side of things keep my belongings neat and clean and be happy when younger each question was assessed on four grades always often sometimes seldom and rarely or never the score for psychological resilience ranged from 0 to 12 with a higher score representing worse psychological resilience risk factors and accommodating factors risk factors included demographic factors and health behaviors gender was categorized as men and women education was measured by years of education we classified smoking as having a smoking habit or not and classified exercise as having exercise habits or not accommodating factors included social supports and were measured by coresidence marital status family income and sp coresidence was categorized as living alone and not living alone marital status was defined as having a spouse and not having a spouse family income was divided into seven levels rmb 0∼9999 rmb 10000∼19999 rmb 20000∼29999 rmb 30000∼39999 rmb 40000∼49999 and rmb 50000 and above respectively coded 05 sp was assessed by asking participants the following questions do you play cardsmahjongg at present do you take part in some social activities at present and do you travel beyond home county the total score was 03 with a higher score representing a better sp data analysis many methods can analyze the apc effects such as intrinsic estimation generalized constrained estimation the crossclassified random effect model and the hierarchical logistic model in this study apc effects were analyzed using a hierarchical logistic growth model which can be employed in the analysis of longitudinal data and does not require specific constraints the hierarchical logistic growth model classified timevarying variables into level 1 and timeinvariant variables into level 2 we conducted a series of hierarchical logistic models to examine age and cohort trends and explored related factors in which age residence coresidence marital status smoking exercising chronic disease and psychological resilience were all included in the level 1 part of the model as they are timevarying variables cohort gender education and attrition were included in the level 2 part of the model as they are timeinvariant variables the square term of age was used to estimate the nonlinear effects of age cohort was included as a categorical variable consistent with most previous studies period was not included in the model due to the collinearity of age period and cohort effects we used sas 94 and glimmix procedure to perform the analysis the model is shown as follows level 1 ln β 0j β 1 age i β 2 age i 2 k k3 β k covariate ki level 2 β 0j π 0 γ 01 cohort 1j q q2 γ 0q covariate qj c 0j to explore the contribution of each element to the disablement process we added the variables into the model separately we compared the or values before and after including each covariate variable separately in the model and then estimated the contribution of each variable the formula is shown as follows contributions results descriptive characteristics the sample descriptive characteristics based on cohorts are shown in table 1 the results showed that older adults in more recent cohorts suffered less from adl iadl and fl disabilities individuals were younger in more recent cohorts women had a higher proportion than men in earlier cohorts which was narrowed in more recent cohorts the proportion of urban older adults increased from 44 in the 1905 and earlier cohort to 52 in the 1946 and subsequent years cohort in more recent cohorts older adults had better psychological resilience higher income higher sp and better education they smoked and exercised more as well greater proportions of respondents had a spouse in more recent cohorts figure 1 displays the age trends of adl fl and iadl disabilities which increased from 0003 0046 and 0044 at the age of 65 years to 0329 0719 and 0955 at the age of 105 years respectively overall the age trend for iadl disability was the highest among the three kinds of disabilities followed by the fl disability and the age trend for adl disability was the lowest figure 2 displays the cohort trends of adl fl and iadl disabilities with 0 to 9 representing the 1905 and earlier cohort and the 1946 and subsequent years cohort respectively the results showed that the cohort trends of adl fl and iadl disabilities increased from 0029 0201 and 0509 in the 1905 and earlier cohort to 0147 0406 and 0748 in the 1946 and above cohort respectively overall the cohort trend of iadl disability was the highest among the three types of disabilities followed by fl disability and adl disability had the lowest cohort trend table 2 shows the contributions of disablement process factors to cohort trends in adl iadl and fl disabilities as for risk factors gender had made a considerable contribution to disability and negatively contributed to cohort trends in fl and iadl disabilities and the contributions decreased from 147 and 3471 in the 19062010 cohort to 99 and 217 in the 1946 and above cohort except for the 19062010 cohort residence also made sizable contributions and positively contributed to the cohort trends in adl disability among older adults and the contributions increased from 33 in the 19111915 cohort to 178 in 1946 and later cohort education was also an important contributor and negatively contributed to the cohort trends in disability and overall the contributions were larger in more recent cohorts health behaviors also significantly contributed to cohort trends in disability smoking positively contributed to the disability trend and the contributions to fl and adl increased from 56 and 33 in the 19062010 cohort to 98 and 74 in the 1946 and above cohort and the contributions to iadl increased from 51 in the 19111915 cohort to 145 in the 1946 and above cohort exercise positively contributed to the cohort trends in adl and iadl disabilities and the effects of iadl disability decreased from 1353 to 114 exercise also negatively contributed to the cohort trend in fl disabilities and the contributions increased from 14 in the 19062010 cohort to 245 in the 1946 and after cohort overall chronic disease positively contributed to the increment of cohort trends in disability and the contribution had increased from 07 07 and 00 in the 19062010 cohort to 300 260 and 385 in the 1946 and later cohort psychological resilience had relatively few contributions to cohort trends in disability as for accommodating factors family income made a positive contribution to the increment of cohort trends in adl disability but a negative contribution to cohort trends in fl and iadl disabilities having a spouse showed negative effects on adl disability in the earlier cohorts which then turned into a positive one from 529 to 123 in later cohorts living arrangements and sp made relatively minor contributions to cohort effects in disability sensitivity analysis figure 3 displays the age trends in disability without controlling for the cohort effect which showed a higher disability level at the age of 65 years and a lower increasing rate compared to figure 1 figure 4 displays the results of the cohort trends in disability without controlling for the age effect and the results showed declining cohort trends while the results in figure 2 showed increasing cohort trends discussions this study explored age and cohort trends in disability and related factors among chinese older adults we found increasing age and cohort trends in adl iadl and fl disabilities and the results of the sensitivity analysis indicated that neglecting cohort or age effect can cause significant bias when estimating time trends in disability more specifically the age trend in fl was lower than iadl but higher than adl we also found that iadl disability and fl began earlier than adl disability the results were consistent with those of other studies according to the disablement process model fl eventually leads to adl and iadl disabilities in this study the results further indicated that fl was more likely to result in iadl disability than adl disability our results have policy implications and health policies such as the health country action in china and other countries similar to china should pay more attention to identifying and reducing fl to prevent disabilities especially iadl disability older adults in more recent cohorts suffered more from disabilities after controlling for age and other disablement process factors the results were inconsistent with those of zhangs studies conducted in china which found decreasing cohort trends in disabilities two reasons may explain the inconsistent results one was because a different method was used to estimate the apc model zhangs study used an ie estimator while the current study used the hierarchical logistic model the other difference between the two may be that zhangs study focused on the oldestold while our study focused on older adults younger than those in zhangs study according to our study health policies such as longterm health insurance should increase the financial support for older adults in a younger cohort in our study we found decreasing trends in disabilities in descriptive analysis and sensitivity analysis and the main reason was that the age effect was not controlled for and younger age was more likely to be part of the earlier cohorts based on the disablement process model we further explored the contributors of cohort trends in disability as for demographic factors gender negatively contributed to cohort trends in iadl disability and fl which was consistent with what was observed in another study we also found that the contributions decreased in more recent cohorts the improvement in the socialeconomic status of women in more recent cohorts may explain the result hence health services should pay more attention to the health demands of older women in earlier cohorts residence positively contributed to the cohort trends in adl disability among older adults and the contributions were larger in more recent cohorts the development of urbanization has expanded the gap between urban and rural public resources this calls for a more equitable distribution of health resources between rural and urban areas education reduced the increasing trends in disability which was consistent with observations from another study moreover we also found that the negative contributions were larger in more recent cohorts this may be because older adults in more recent cohorts obtained more education and had more health resources or health knowledge to maintain functional health in later life therefore more health services should be provided for older adults in earlier cohorts as for health behaviors drinking positively contributed to the cohort trends in disability with larger contributions in more recent cohorts exercise negatively contributed to the cohort trends in fl disability and the effects were larger in more recent cohorts the results were inconsistent with those of chen and franks study which only found minor contributions of health behavior to disability trends the difference might have been caused by chen and frank only using twotime point data older adults were more likely to smoke and exercise in more recent cohorts which may explain these results however exercise also positively contributed to cohort trends in adl and iadl disabilities and the contributions increased in more recent cohorts this outcome could be because disabled older adults were more likely to change their unhealthy lifestyles therefore health policies such as the health country action in china and other countries similar to china should promote exercise in older adults in earlier cohorts and reduce smoking in more recent cohorts as for social support family income made the largest contribution to cohort trends in iadl and adl disabilities showing a negative contribution to cohort trends in iadl disability but a positive contribution to the increment of cohort trends in adl disability the results were inconsistent with those of zajacovas studies which only found declining trends in economic status which were associated with increasing disability prevalence the reason may be that zajacovas study did not distinguish between adl and iadl disabilities current results might be explained by the fact that higher family income was more likely to prevent mild disability while it can only maintain the lives of older adults with severe disability the results indicated that families should provide timely support to prevent mild disability in older adults overall the contributions of family income were larger in more recent cohorts the results could be explained by the rising family income in more recent cohorts as older adults had low family incomes health services such as integrated medical and nursing services should be provided more affordably to older adults especially in earlier cohorts it is also necessary to promote the establishment of longterm care insurance in china and other countries similar to china to provide support for less severe disabilities and eventually improve the functional health of older adults and reduce the longterm care burden to the family we only found minor contributions of living arrangement to cohort trends in disabilities and increasing negative contribution of having a spouse which may be caused by fewer children in the family and the increase of emptynest older adults in more recent cohorts thus policies in china and other countries similar to china should encourage children to live with their parents in the future for the disablement process we found that chronic disease positively contributed to the escalations of cohort trends in disabilities previous studies showed that chronic disease had a large effect on disability trends among older adults which was consistent with the results of our study increases in chronic disease in more recent cohorts may explain these results according to our studies health policies such as the health country action in china and other countries similar to china should conduct interventions for chronic disease in more recent cohorts to prevent disability among older adults limitations and strengths this study has several limitations first as longitudinal data were used in our study the period effect was not included in the apc analysis however as our study focused on older adults the span of the period was much shorter than age and cohort so the effect of period could be trivial and omitted from the model second although we used longitudinal data we were still unable to isolate the causal direction of related factors of cohort trends in disability such as exercise and family income third the measurement of disability was gathered from selfreported surveys which may cause bias however selfreported data are commonly used in disability research of older adults which can reflect more accurately personal status interacting with the real world finally our study only calculated the total contributions of each disablement process factor which did not explore the relationships between these contributions therefore more studies are needed to explore the mechanism of the contributions nonetheless this study contributes to the existing literature in four aspects first this study used fivewave national representative longitudinal data in a developing country which allowed us to better investigate age and cohort trends in disability and explore contributors to cohort trends in disability second it was conducted in the chinese context which fills the gap of lacking apc analysis beyond the developed countries third this study combined adl iadl and fl to study age and cohort trends in disability and related contributors of cohort trends in disability which can better reveal the disability trends and related contributors of disabilities finally we also added the disablement process model by revealing the age and cohort trends in disability and the contributions of disablement process factors to cohort trends in disability conclusions our study draws the following conclusions first in light of the declining fertility rate and the rapidly aging society our study showed that the likelihood of disability has increased in both age and cohort trends this requires society to pay more attention to reducing disability among older adults second our study gauged the relative importance of the disablement process factors in explaining cohort trends in disability necessitating more precise interventions to reduce disability among older adults finally our study divided temporal trends into two dimensions age and cohort and explored various effects of relevant factors on cohort trends in disability it may invoke further research in this area across different cultural contexts and populations and provide interventions for disability among older adults of other countries similar to china data availability statement the datasets presented in this study can be found in online repositories the names of the repositoryrepositories and accession number can be found in the articlesupplementary material publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

objective this study aimed to examine age and cohort trends in disability among chinese older adults and explore the disablement process factors that may explain the cohort trends in disability methods this study used data from five waves of the chinese longitudinal healthy longevity survey clhls a hierarchical logistic growth model was used to analyze the apc e ects and the contributors of cohort trends results adl iadl and fl among chinese older adults showed increasing age and cohort trends fl was more likely to result in iadl disability than adl disability among the disablement process factors gender residence education health behavior disease and family income contributed to most of the cohort trends in disability conclusions as older adults face increasing disability trends it is necessary to distinguish age and cohort trends and develop more e ective interventions according to relative contributors to prevent disability among them

introduction the human immunodeficiency virus targets the immune system especially the cd4 cells that help the immune system fend off infections without intervention hiv reduces the number of cd4 cells increasing vulnerability to infections or infectionrelated cancers and resulting in acquired immunodeficiency syndrome over time once a person contracts hiv they have it indefinitely individuals with hivaids often experience a range of cognitive motor and emotional issues collectively referred to as hivassociated neurocognitive disorder common indicators encompass challenges related to focus cognitive capacity and recollection diminished drive heightened irritability feelings of depression and decreased physical speed however consistent antiretroviral therapy allows the infected to lead long healthy lives and decreases the risk of passing the virus to others although current treatments do not cure hivaids they can control the virus effectively enabling positive individuals to have lifespans comparable to those without the virus direct contact with certain body fluids from a person with hiv such as blood semen vaginal fluids rectal fluids and breast milk primarily leads to hiv contraction common transmission methods thus encompass unprotected sexual contact sharing needles or syringes receiving tainted blood products or organ transplants and transmission from mother to child during childbirth or breastfeeding 1 2 over the past decades research has evolved from a sole focus on individual behaviors to understanding the environments where hivsti risk behaviors take place according to a studys risk environment framework these environments fall into physical economic social and policy categories 3 in essence regular testing safe sexual practices and integrated journal for research in arts and humanities issn 25831712 volume3 issue5 september 2023 pp 3511 preventive measures like expanding needle and syringe program coverage and hiv screening tests during blood transfusion can greatly decrease the risk of contracting or transmitting hiv 4 5 since its emergence in the late 20th century when many labeled hivaids as the gay plague the hivaids epidemic has not only posed a health challenge but has also exposed societal fears and misconceptions 6 the history of hivaids thus intertwines with the ongoing trauma of stigma and discrimination as those diagnosed usually face social exclusion and workplace biases stigma perceived as a mark of disgrace associated with a particular circumstance quality or person has consistently affected many of those with hivaids 7 discrimination defined as unfair treatment due to the virus compounds the challenges the infected individuals encounter 8 the combination of stigma and discrimination thus creates environments where many with hivaids often feel marginalized misunderstood and mistreated hence the need for coping mechanisms although they can all act as essential tools for handling the challenges of stigma and discrimination some coping strategies might amplify the feelings of isolation and despair whereas others can foster resilience understanding and acceptance while stigma and discrimination persist many recent studies have centered on the growth and diversification of coping mechanisms due to new technology which can foster improved mindsets and attitudes i have an emotional connection with this subject through one of my dearest friends an outstanding young woman who contracted the virus from a blood transfusion during her childhood after graduating and then earning a masters degree from the university of bucharest she had to deal with numerous job rejections because of her health status but her optimism and forgiving nature always helped her move on we once envisioned starting a venture to support stray animals which would have offered her a life filled with dignity and purpose yet her untimely departure has left a void and now stands as a constant reminder of the urgent need to address the stigma and discrimination faced by those like her i dedicate this research to miha a beacon of hope and resilience … ii research method while exploring the widespread issues of stigma and discrimination this study aimed to identify the coping mechanisms that individuals living with hivaids had to employ on a daily basis an extensive literature search on hivaids thus took place which included browsing online databases and studying many types of materials the search utilized keywords such as hiv aids stigma discrimination coping strategies and other related terms after the initial stage numerous articles books films documentaries reports and other resources were accessed in order to ensure a broad spectrum of viewpoints and results a careful selection process then took place to choose the most representative and pertinent literature which required evaluating each source for its relevance authenticity and alignment with the studys main theme the final sample included a significant mix of academic and nonacademic official and personal sources that could offer valuable insights into individual and societal behaviors and beliefs and the coping strategies of those with hivaids given my nationality certain romanian reports and resolutions also became part of the study for a more comprehensive and authoritative view on the topic ultimately the research methodology stems from a personal commitment to enriching the conversation on managing hivaidsrelated stigma and discrimination iii global perspectives drawing from a multitude of materials this study ultimately seeks to identify the most effective coping strategies in mitigating the challenges posed by stigma and discrimination below are the timelines of the resources used in this study as well as their approaches to the topic of stigma discrimination and coping articles stigma back in the mid1990s a study described how stigma adapted throughout the progression of the illness its trajectory thus starts with the at risk phase where individuals waiting for a diagnosis grapple with anxiety and fear upon receiving a positive hiv result the infected face a shift in their personal identity which represents the diagnosis phase in the latent stage the individuals with hiv have to deal with the challenges of disclosure and societal views as the illness advances the manifest phase ensues so this demographic will deal with social exclusion due to the visible signs of aids the study underscores the importance of understanding this stigma trajectory in order for societies to offer those with hivaids the right support and interventions 9 delving into the social and psychological implications of blaming individuals with hivaids another study underscored the association of aids with gay men and lesbians as their research identified an increased aggression toward this population segment the application of attribution theory provides insights into public reactions to the health status of notable figures indicating how causal responsibility inferences shape emotional responses the findings highlight the importance of public policy and educational interventions for addressing the deeply ingrained prejudices and misconceptions surrounding hivaids 10 two years later another paper showed that many older individuals viewed suicide as a coping mechanism to escape terminal illness thus stressing the challenging intersection of age hiv status and mental health the limitations of the study included the crosssectional design and reliance on selfreported data 11 through telephone surveys conducted over different time intervals three researchers delved into the prevalence of misinformation and misconceptions about hiv transmission during the 1990s in the united states while overt expressions of hivaidsrelated stigma witnessed a decline these shifts in public attitudes could not prevent the increase in inaccurate beliefs about the risks associated with casual social contact moreover the study noted a rise in the belief that people with aids deserved their condition 12 in the same year three other scholars analyzed the phenomenon of internalized stigma among individuals living with hivaids their study thus shows how the infected internalize negative societal beliefs and stereotypes about their condition which leads to selfstigmatization the findings ultimately highlight the effects of internalized stigma on mental health outcomes treatment adherence social isolation and coping mechanisms 13 by connecting it to the reproduction of social differences a paper proves how stigma reinforces and perpetuates existing inequalities spanning class race gender and sexuality the authors reject individualistic approaches advocating programmatic strategies that use the resistance of stigmatized individuals and communities as resources for effecting social change 14 three years later yet another study focused on the impact of sexual orientation and the necessity of awareness campaigns and interventions like others before them the authors aimed to uncover the implications of misconceptions biases and societal prejudices for the wellbeing and social acceptance of hivpositive individuals indicating that lgbtq individuals faced intensified stigma due to historical links between hivaids and sexual orientation the study references the justworld theory which postulates that people blame victims for their misfortunes the belief in a just world is discussed from two perspectives explicit endorsement and a fundamental need both indicating how societal trends influence prejudices against hivpositive individuals and how attitudes can vary based on sexual orientation 15 in a similar vein another paper delves into the effects of hivrelated stigma among patients receiving antiretroviral therapy in botswana once again the findings highlight the widespread nature of hivrelated stigma affecting patterns of disclosure social interactions and even hiv testing behaviors an overwhelming 94 of patients kept their hiv status secret from their communities and 69 did not even disclose it to family members the fear of losing jobs due to hiv status was also prevalent with 27 expressing such concerns moreover 40 of patients delayed hiv testing due to the stigma associated with a positive result the conclusion emphasizes that scaling up national art programs necessitates targeted efforts to address stigma and its associated economic social and political factors 16 undoubtedly the impact of stigma on various aspects of individuals lives can lead to nondisclosure and delayed testing thus hindering access to treatment and care that is why a more sustainable theory of healthrelated stigma should be grounded in more empirical evidence in order to consider the diverse experiences of affected individuals across various cultural and social contexts by building on the lessons learned from the hivaids literature another paper advocates a holistic understanding of healthrelated stigma which can inform research policies and interventions aimed at reducing stigma and promoting social inclusion 17 a year later a similar study explored the influence of hivrelated stigma on hiv care and prevention providers within us communitybased organizations using the hiv provider stigma scale the findings revealed that heterosexual hiv service providers especially those with less experience in the hiv field reported higher levels of stigma implications highlight the importance of sustaining the workforce considering interventions to address stigma and ensuring the optimal delivery of services to patients 18 in a collective attempt to convey the challenges in defining measuring and addressing hivaidsrelated stigma other researchers conducted a comprehensive review of the literature on this formidable barrier to effective responses to the epidemic the multifaceted approach encompassed improved research methodologies and targeted interventions as well as a deeper understanding of the sociocultural dynamics perpetuating stigma 19 using a unique perspective another study delves into the relationship between hivaids motherhood and national identity as portrayed in relevant south african choreography the article thus examines the term mothertochild transmission of hivaids and its implications in the south african context while the choreography serves as a special medium to question societal perceptions especially how women often get portrayed as the primary carriers and transmitters of the disease the study also touches upon the historical role of south african women in the struggle against apartheid and their subsequent role in the fight against hivaids the choreographic works discussed therein aim to challenge static representations of gender race sexuality and the stigmatization associated with hivaids through dance the article ultimately explores the cultural and societal beliefs attached to body fluids transmission and the broader implications of hivaids in the south african societal fabric 20 in yet another attempt to address the conceptualization and measurement of hiv stigma mechanisms two researchers introduced the hiv stigma framework as a way of comprehending how the social devaluation of hiv impacts both uninfected and infected individuals their study calls for more research into how individuals experience hiv stigma and its outcomes with recommendations to consider these aspects when developing survey instruments 21 a year onward other scholars delved into the predictors of hiv testing acceptance among tuberculosis patients in north ethiopia the findings revealed that knowledge and stigmatic attitudes played pivotal roles in influencing the acceptance of hiv testing the studys recommendations included tailored education for the community as well as tb patients in order to raise awareness about the benefits of hiv testing 22 another study focused on the creation and validation of the hiv and abuse related shame inventory which measured the impact of shame on individuals with hiv especially on those with a history of childhood sexual abuse the findings showed that hivrelated shame could predict hiv transmission risk behaviors and reduced quality of life while csarelated shame linked to depression ptsd symptoms and other negative outcomes 23 in line with previous research a more recent paper explored the mediating roles of internalized and anticipated hiv stigma in the relationship between perceived community stigma and various health and psychosocial outcomes the study thus provided insights into how internalized anticipated and perceived stigma contributed to outcomes such as selfesteem depressive symptoms coping strategies medication adherence social support and physician trust 24 discrimination a 2003 article discusses the challenges faced by men who have sex with men in dakar senegal in the context of hiv vulnerability using ethnographic and survey methods the study found that 43 of msm reported verbal abuse from their families and communities with some also facing the physical type the research highlights the importance of providing nonstigmatizing sexual health services tailored to msms needs most participants expressed a preference for the formal health system as long as they received respectful and confidential treatment 25 seven years later another paper provides an encompassing overview of the challenges faced by msm in developing nations through a range of studies and reports the researchers examine societal recognition of gay rights as well as the prevalence of hiv among this population segment 26 in a similar vein the authors of a study on hivrelated discrimination in romania interviewed 115 individuals from bucharest constanța and neamț findings indicated that 52 felt discriminated while 72 reported discriminatory experiences despite 61 being aware of their rights only 46 knew where to report discrimination and just 5 did so participants recommended public hiv education stricter discrimination penalties and more involvement of hivpositive individuals in antidiscrimination efforts conducted between december 2006 and january 2007 the research primarily involved romanian antiaids association beneficiaries due to hiv stigma additionally the study included a questionnaire further delving into the experiences and perceptions of the participants 27 regarding discrimination within healthcare settings a 2005 study stresses the crucial need to increase awareness so that all infected individuals can receive equitable and respectful care 28 another study contributes insights into the perception and behavior of healthcare providers toward ethiopian individuals living with hivaids the rapid spread of the virus and disease in ethiopia strained both the healthcare system and its providers leading to concerns about safety providerpatient relationships and working conditions through a combination of quantitative and qualitative methods like indepth key informant interviews and focus group discussions the study revealed that hivaidsrelated discrimination was particularly entrenched within the healthcare environment influenced by factors such as misconceptions about transmission and personal fears providers would thus label patients based on hivaidsassociated symptoms the study recommends intensive training for healthcare providers improving working conditions and enhancing community awareness of hivaids 29 similarly another study presents the attitudes of nonphysician healthcare providers toward hivaids in nigeria also revealing gaps in knowledge about hiv transmission along with misconceptions such as transmission through mosquito bites or handshakes 30 three years later yet another article acknowledges the farreaching consequences of stigma on careseeking behavior and public health environments as before among the common causes of discrimination the researchers emphasize a lack of awareness among healthcare workers alongside misconceptions about hiv transmission effective interventions according to the study should encompass individual environmental and policy levels showcasing strategies like equipping health workers with both knowledge and protective outfits and fostering nonjudgmental environments through participatory methods the study highlights the potential for positive change in health providers attitudes and behaviors 31 in line with previous research a study on southwest ethiopian healthcare system employed a crosssectional quantitative approach supplemented by qualitative interviews and focus group discussions in order to reveal that hivaidsrelated discrimination was particularly linked to extra precaution fear of workrelated transmission and lack of safety the findings demonstrate that healthcare providers with higher hiv knowledge and education exhibit lower discrimination scores so attending proper training can contribute to score reduction unofficial disclosure of clients hiv serostatus by healthcare providers to ensure extra precautions was also noted which underscored the need for communitybased interventions to mitigate discrimination among healthcare providers 32 similarly a more recent study highlights the existence of various forms of discrimination against people living with hivaids within healthcare settings in surat india the findings specifically reveal instances of harassment from healthcare staff unjust charges by private practitioners changes in treatment modality and the practice of taking extra precautions during treatment hiding ones hiv status due to fear of discrimination and avoiding doctors and hospitals emerged as strategies to cope with the challenges the study ultimately underscores the need for sensitization and training of healthcare professionals to provide equitable and nondiscriminatory care 33 two years later another paper focused on the occurrence of discrimination among healthcare providers in guangzhou china conducted as a crosssectional survey the study involved a substantial number of 34 coping one year before the new millennium a paper focused on the coping strategies and psychosocial experiences of middleaged and older adults living with hivaids the researchers noted that the factors contributing to depression consisted of hivrelated stigma loneliness selfreported memory problems low energy and the longing for a younger age the study also found that women living with hivaids received fewer social assistance and therefore experienced more depression than men in essence lack of social support coupled with stigma and financial difficulties contributed to elevated depression and even suicidal ideation 35 a later study also focused on coping strategies for older hivpositive adults who faced additional challenges such as comorbidities and ageismrelated stigma given that these individuals often lacked support mechanisms from family and community adaptive coping proved crucial for their emotional wellbeing the study utilized the ways of coping checklist and the hivrelated life stressor burden scale to assess the coping strategies and stressors the findings revealed elevated grief reactions psychological distress and depressive symptoms among participants recommendations emphasized the need for interventions tailored to older adults with hivaids 36 utilizing the framework of the chronic illness quality of life model three other researchers also delved into the complexities of depressive symptoms experienced by older adults diagnosed with hiv a significant proportion of this demographic was found to grapple with moderate to severe depression linked to diminished physical wellbeing and a lack of social support factors such as the nature of the loss past drug use and existing depressive symptoms further exacerbated the severity of depression notably engagement coping and social support were found to be interrelated the latter playing a crucial role in reducing cognitiveaffective symptoms 37 on a more general note other scholars explored the psychological challenges faced by hivpositive individuals who exhibited heightened levels of grief depression anxiety andor traumatic stress the severity of the feelings was influenced by escapeavoidance and selfcontrolling mechanisms as well as factors like the type of loss depressive symptoms and a history of drug use the research provides crucial insights into the emotional complexities of hivpositive individuals and the importance of support mechanisms in navigating their grief 38 a 2005 study explores the benefits of a group intervention designed to assist hivpositive individuals in managing hivaidsrelated bereavement while suggesting genderspecific responses the cognitivebehavioral bereavement coping group intervention demonstrated its effectiveness in positively influencing the healthrelated quality of life for both hivpositive men and women the findings ultimately underscore the critical need for interventions that holistically address both the emotional and physical wellbeing of this demographic 39 in the same year other researchers also examined the influence of gender and ethnicity on the coping strategies of bereaved hivpositive individuals and discovered that gender and ethnicity indeed had significant effects on spiritual coping independent of perceived social support thus women and ethnic minorities employed spirituality for coping while white men used it the least and white women used avoidant coping more than white men ultimately the nuanced ways in which different groups process grief underscores the need for culturally sensitive interventions 40 a year later a new study delved into the connection between race social support and coping strategies among hivpositive gay and bisexual men aiming to comprehend how racial backgrounds impacted coping mechanisms the study emphasized the complex intersection of race sexual orientation health and social support while it linked high social support to active coping and low support to selfdestructive responses the findings acknowledge racial variations in coping and thus underscore the requirement for culturally sensitive interventions especially for those facing double stigma related to both race and hiv status 41 since coping strategies significantly influence how individuals deal with stress effective coping can lead to better psychological outcomes a 2009 study introduced a group intervention model based on cognitivebehavioral coping and delivered it in a social support group context the model comprised components like building social support addressing challenges related to aids loss and implementing adaptive coping strategies the results indicated that participants could experience significant reductions in depression grief reactions intrusive experiences demoralization and psychological distress both immediately after the intervention and at a 3month followup further research was recommended to validate the findings and explore longterm benefits of cognitivebehavioral coping strategies integrated within a supportive group setting for bereaved hivpositive individuals 42 in line with the previous works yet another study explored the hypothesis that the impact of stigmarelated stressors on psychological wellbeing varied based on the coping strategies employed by people living with hivaids by examining 200 participants the study scrutinized selfreported enacted stigma felt stigma coping mechanisms depression anxiety and selfesteem the results highlight the relationship between felt stigma and coping strategies on individuals selfreported depression anxiety and selfesteem thus participants who employed disengagement and experienced increased felt stigma reported higher levels of anxiety and depression whereas this association was less pronounced among those who employed engagement 43 in a similar vein other researchers explored the psychological impact of childhood sexual abuse on hivinfected individuals and how a coping intervention like living in the face of trauma could reduce traumatic stress the findings showed elevated grief reactions and distress related to losses while lifts effectiveness in reducing traumatic stress was mediated by decreases in avoidant coping strategies 44 in 2015 another article investigated how people from tamil nadu south india coped with being hivpositive shame worthlessness fear of ostracism guilt and anger were among the feelings triggered by stigma as a result participants navigated various coping strategies including clear knowledge of hiv seeking social support selective disclosure of their status empowerment through employment and participation in positive networks 45 a 2016 study explored the utilization of providerinitiated hiv testing and counseling among adult outpatient department patients in a specific region of ethiopia the findings revealed that while 784 of participants utilized pitc a substantial portion refused to do so low knowledge about hiv along with individual factors such as marital status gender awareness about pitc and prior hiv testing influenced pitc utilization the study recommends strengthening targeted health information through mass media and awareness campaigns to enhance pitc uptake among adult opd patients and peer education to overcome barriers to testing 46 more holistically other scholars explored the impact of integrated yoga intervention on the landscape of hivrelated stigma particularly on anxiety depression and cd4 counts conducted in northeast brazil the study found that practicing iy for a month could lead to a significant reduction in depression and an improvement in immunity as evidenced by increased cd4 counts in hiv1 infected adults the research thus emphasizes the potential benefits of yoga as a complementary approach in the conventional management of hiv1 infection highlighting its role in enhancing psychological wellbeing and boosting immunity 47 two years later a new study also examined the potential advantages of yoga as a stress management tool for individuals diagnosed with hivaids in northeast brazil the research utilized a systematic review and metaanalysis approach to assess the impact of yoga interventions on psychological distress among the infected once again the findings indicate that yoga can significantly reduce psychological distress and can improve overall wellbeing in this population however the literature remains limited due to the small number of studies available at the moment the article therefore emphasizes the need for more randomized controlled trials with objective measures of hivrelated outcomes to further evaluate the benefits of yoga for people living with hivaids 48 in the same country another paper employed a crosssectional quantitative analysis with 331 participants receiving treatment at an outpatient clinic and utilized the coping strategies inventory to gather data the findings indicated the predominance of emotioncentered coping methods such as positive reappraisal along with the influence of various sociodemographic clinical and lifestyle variables on these coping strategies for instance individuals who practiced a religion or lived with family members exhibited higher mean scores in several coping factors once again the research underscores the importance of understanding the psychological and social aspects affecting people living with aids in order to provide comprehensive and interdisciplinary care 49 in 2019 several researchers delved into the reasons why people living with hiv in france engaged or refrained from physical activity their study recognized the numerous benefits of pa such as improved physical and mental health yet noted that a significant portion of this population remained inactive through facetoface semistructured interviews with 15 participants the research aimed to identify the barriers and facilitators influencing their involvement in pa the seven men and eight women recruited from hospitals in central and southern france and undergoing antiretroviral therapy ranged in age from 40 to 65 while the interviews focused on participants perceptions and beliefs about pa in their daily lives the study also used the dijon pa score to assess participants activity levels categorizing them as active inactive or seasonal exercisers the findings revealed a multidimensional perspective with barriers and facilitators spanning physical psychological and socioenvironmental domains thus despite recognizing the benefits of pa many hivpositive individuals faced barriers such as respiratory issues low energy levels lack of motivation and environmental challenges on the other hand factors like family support community environment and structured exercise routines served as facilitators the study ultimately underscores the need for tailored interventions and promotional strategies to encourage pa among people living with hiv in france 50 similarly a systematic review and metaanalysis examined the impact of mindbody therapies specifically meditation and yoga on the immune system and mental health of people living with hiv the study incorporated 19 randomized controlled trials with a total of 1300 participants the results indicated that such therapies significantly improved cd4 tcell counts a crucial marker of immune function in the infected additionally the efficacy of these interventions on cd4 improvement appeared more pronounced in individuals with lower baseline cd4 counts and fewer years since their hiv diagnosis the analysis thus revealed that meditation and yoga significantly reduced symptoms of stress depression and anxiety while enhancing quality of life the findings ultimately suggest that integrating costeffective meditation and yoga practices into the routine care of people living with hiv could offer potential benefits especially for those diagnosed more recently and furthermore the study explored the integration of technology in hivrelated healthcare and fitness which could guide clinicians in recommending proper exercise regimens and ultimately shape the design of future research and trials in this area 53 similarly a 2022 study focused on the physical health of children and adolescents on antiretroviral therapy in mozambique evaluating indicators such as body composition physical fitness and habitual physical activity levels the study compared the physical health of hiv subjects with nonhiv mozambican peers from urban and rural areas preliminary findings suggested that this demographic experienced negative impacts on their somatic growth physical fitness and regular physical activity due to factors like socioeconomic status mitochondrial toxicity and psychosocial circumstances additionally many children and adolescents living with hiv appeared to be smaller had lower body weight and entered puberty later than their healthy peers the final results thus indicated that a significant proportion of the hiv subjects were classified as unfit especially in areas such as abdominal strength and endurance however no noticeable difference was observed in flexibility overall the research underscores the need for a deeper understanding of the multifaceted challenges faced by children and adolescents living with hiv in mozambique especially concerning their physical health and wellbeing 54 chapters first of its kind a 2013 academic book defines stigma as a discrediting attribute that leads to discrimination and presents a comprehensive compilation of empirical research across diverse cultural contexts by providing valuable insights into reallife situations each chapter thus aims to help healthcare providers offer more culturally sensitive services based on the experiences of individuals and groups with hivaids 55 stigma discrimination by exploring the nature of prejudice and societal perceptions of hivaids two researchers focus on the mechanisms of internalized anticipated and enacted stigmas the chapter underscores the importance of viewing hiv stigma as a social process and highlights the need to recognize the structural and interpersonal drivers of hiv stigma within specific sociocultural contexts to craft effective interventions given that individuals with hiv often grapple not only with their positive status but also with drug use sex work raceethnicity and poverty the study also illuminates how hiv stigma intertwines with these intersecting stigmas influencing the overall experiences of these individuals the chapter wraps up by spotlighting south africa as a case study for the intricacies of confronting hivrelated stigma within specific cultural landscapes 56 a novel conceptual framework connects the structure of aids stigma to gender as a societal structure emphasizing the importance of understanding the gendered experiences of stigma one scholar thus focuses on the intersection of gender dynamics and aids stigma while showing how gender relations contribute to the perpetuation of aids stigma and how men and women often experience stigma differently the chapter also highlights the significance of a gender analysis in creating effective aids prevention programs 57 similarly two other experts examine gender disparities in hivrelated stigma perception and community support among individuals with hivaids in thailand analyzing the variations in stigma experiences and community backing between thai men and women living with hivaids the study reveals that males receive less community support and therefore perceive higher levels of stigma compared to females marital status and geographical location also influence stigma experiences the study ultimately emphasizes the need for tailored interventions to address genderspecific challenges faced by hivpositive people in thailand 58 coping exploring societal contexts another chapter considers the importance of family support and culturally sensitive interventions while yet another discusses the management of hivstatus disclosure through healthcare providers 59 60 focusing on stigma within healthcare settings other researchers advocate more sensitive and patientcentered care practices 61 exploring the human interactions in china one study promotes awareness campaigns that challenge sociocultural norms and rely on empathy and understanding 62 while a similar one highlights the societal norms and beliefs that contribute to stigmas impact on colombian people living with hivaids the latter also explores ethical and legal responses to stigma while emphasizing the role of healthcare institutions coping by analyzing the sympathy and discriminatory attitudes of women in public housing the author proves that challenges still persist while many start to believe in inclusive education and workplaces 65 coping strategies consist of fostering awareness correcting misconceptions and utilizing personal stories to combat stigma by exploring hivrelated stigma among latinos on the usmexico border a scholar emphasizes the unique sociocultural context of the region the study advocates for culturally tailored interventions that can address the psychological impact of stigma and promote a supportive environment for disclosure 66 the next study reveals how hivrelated stigma in south africa can lead to death immorality and deviation from cultural norms the researchers call for awareness campaigns to challenge misconceptions foster community support and address the internalized stigma that affects the psychological wellbeing of hivpositive women and their willingness to disclose their status 67 yet another research focuses on the layered stigmatization faced by men who have sex with men in south africa due to sexual orientation and hiv status the chapter underscores the need for creating msmfriendly health facilities combating homophobic norms and ensuring access to comprehensive healthcare services 68 similarly two studies explore the emergence of gay identities in china and the discrimination faced by msm due to clashes with traditional values the researchers emphasize the need for innovative prevention efforts culturally tailored interventions and proper education for bridging the gap between traditional beliefs and modern realities 69 70 categorizing spaces as personal and impersonal empowering and disempowering two scholars delve into the spatiality of hiv status revealing and discrimination in india the study advocates creating safe spaces for disclosure addressing the challenges of various settings and designing interventions tailored to the spatial context 71 adding to the stigma literature another chapter focuses on comparing the experiences of hivpositive and hivnegative gay men in australia the findings indicate that while hivpositive men reported low levels of stigma in terms of attributions of responsibility and social distancing they faced higher negative emotional reactions and also exclusion from sexual or romantic partnerships surprisingly stigma experiences were similar between hivpositive and hivnegative men which reveals a serostatus divide within the gay community coping strategies entailed addressing emotional impacts of stigma promoting inclusivity and reducing serostatusbased divisions 72 the next study explores the stigmatization of hiv and hepatitis c coinfection among gay men in london hepatitis c was thus found to be more stigmatizing within the gay male subculture than hiv despite both being sexually transmitted the chapter highlights the emotional toll of hierarchical stigmatization particularly in a subculture where hiv serosorting prevails and therefore calls for raising awareness promoting empathetic ownership and fostering an inclusive community environment 73 while it affects service accessibility and individuals selfesteem stigma can also lead to the formation of solidarity networks that can challenge discriminatory norms a chapter introduces the people living with hiv stigma index as a transformative research model implemented in the uk and malawi the study discusses power participation and social change aspects and reflects on research team experiences and the adaptable nature of the index the findings highlight the importance of addressing stigma through collaborative and adaptable research models 74 underscoring the role of spirituality and the black church in hivaids prevention two scholars discuss faithbased strategies to mitigate stigma experiences within the african american population particularly in older adults that live with hivaids in the rural south the chapters insights are drawn from the authors work in a highprevalence area highlighting the importance of culturally sensitive approaches 75 the last two studies in the academic book explore the experiences of thai individuals living with hivaids in two regions and those of women in central thailand despite the transformative impact of hiv diagnosis on selfworth and societal disgust individuals employed selective disclosure to reconnect with supportive networks foster meaning and reevaluate their worth coping mechanisms included seeking support from groups and buddhist teachings to find purpose and normalcy drawing on multiple references to provide comprehensive insights the second study also discusses public policy responses to hivaids community participation interventions to reduce stigma and the roles of buddhist temples in providing support both findings underline the importance of community involvement and spiritual guidance in empowering those with hivaids to lead dignified lives 76 77 books beyond the academic field works like borrowed time and body counts provide intimate accounts of living with hivaids while fairyland narrates a daughters journey amidst the crisis and her bond with her gay father 78 from personal struggles and societal challenges to political activism and human resilience each book ultimately contributes to a holistic understanding of the epidemic and the stigmas intertwined with it capturing its multifaceted impact on individuals and society films the realm of cinema has also provided a powerful medium to explore the multifaceted dimensions of the hivaids epidemic delving deep into personal struggles and emotional turmoil like the play with the same name the normal heart chronicles the harrowing early years of the epidemic in new york city emphasizing the profound emotional challenges faced by gay men 90 on a more personal note an early frost offers a poignant narrative of a young lawyer grappling with societal judgment after his diagnosis while yesterday captures the resilience and challenges of a young mother diagnosed with aids in rural south africa 91 92 on the activist front and the band played on provides a comprehensive look at the early days of the epidemic adapted from randy shilts journalistic account the film underscores the political apathy challenges in the medical community and the ensuing activism that emerged in response to the crisis 93 on the societal front philadelphia and stigma also spotlight the discrimination and prejudices faced by those with hivaids the former narrates the legal battle of a lawyer who faces discrimination due to his diagnosis highlighting the broader societal biases 94 in the same vein stigma delves into the deeprooted misconceptions and prejudices associated with the disease as it chronicles the harrowing journey of two african women mother and daughter who contract hiv while serving as traditional birth attendants in a village the mother succumbs to societal stigmatization which leads to her tragic demise her daughter faces similar ostracization especially after her mothers aids diagnosis becomes public knowledge moreover when she steps into her mothers shoes vanessa too contracts the virus despite taking more precautions on the brink of ending her life a beacon of hope emerges in the form of an individual who believes in her challenging outdated perceptions this support empowers vanessa to transform her life moving away from her village and using her experience to become a motivational speaker and support those with aids while her success prompts some from her past to seek reconciliation vanessa grapples with the complexities of forgiveness which means that sometimes it might be too late 95 ultimately these films paint a vivid cinematic tableau of the hivaids epidemic emphasizing the personal challenges societal biases and the indomitable spirit of activism beyond their common theme they will all stand as a testament to the enduring human spirit that can battle against the stigmas and prejudices of any time in the history of humankind documentaries the hivaids epidemic has been extensively documented each broadcast offering a poignant exploration into the persistent prejudices faced by those with hivaids how to survive a plague provides a historical perspective chronicling the early days of the epidemic and the rise of activism brutally accurate like the book written years later the program paints a vivid picture of societal and political apathy juxtaposed against the relentless spirit of the hivaids community 96 in a similar vein the lazarus effect delves into the transformative power of antiretroviral drugs in subsaharan africa highlighting the disparities in treatment access and the societal stigmas that compound these challenges 97 more personal common threads stories from the quilt offers a touching tribute to lives lost to aids the names project aids memorial quilt with each panel symbolizing a life stands as a testament to personal stories of love loss and the overarching shadow of discrimination 98 positive youth shifts the focus to the younger generation as it attempts to elucidate the unique challenges they face from grappling with their diagnosis to confronting societal biases the documentary also underscores the crucial role of support education and advocacy in helping young people combat stigma and lead fulfilling lives 99 from a coping perspective these emblematic documentaries stand as powerful testaments to the personal stories societal challenges and the indomitable spirit of communities that have battled against the prejudices related to hivaids websites since coping stigma and discrimination stands as a vital component of the global response to hivaids certain websites play a key role in sharing accurate information challenging false beliefs and supporting those affected the hivaids section of the world health organization provides a detailed look at global strategies guidelines and resources on mental health and psychosocial support for individuals with hivaids 100 advocating for fast comprehensive and coordinated global action against the hivaids epidemic the joint united nations program on hivaids leads in addressing stigma and discrimination through campaigns and initiatives to shift societal views and ensure the rights of the affected like who unaids thebody another vital website offers a wide range of hivaids information while including a personal stories section where people share their hivaids experiences by offering a platform for these valuable narratives thebody humanizes the disease and challenges false beliefs 104 based in the uk avertorg tackles stigma and discrimination with their educational resources offering extensive information on prevention treatment and support the british website also has a section on living with hiv where people offer insights and advice on managing the emotional and social facets of the disease their recently introduced digital brand be in the know consistently offers captivating and userfriendly information about sexual health and hiv to the younger population mainly in east and southern africa this also serves the educators and healthcare professionals within their localities 105 106 the us governments hivgov provides resources and strategies to address stigma and discrimination on both personal and community levels as with the previous websites hivgov underscores the significance of mental health and offers materials to assist individuals in managing the challenges of living with hivaids 107 in romania the unopa website belongs to a unique nongovernmental federation named the national union of organizations of people affected by hivaids its main objective is advocacythat is promoting and defending the rights of those infected and affected by hivaids in romania 108 another important online resource is cnlas the website offers indepth analyses of the current hivaids landscape in romania for stakeholders and policy makers as well as comprehensive snapshots of romanias hivaids scenario from 1985 to the present highlighting the challenges faced by children with hivaids the relationship between drug use and hiv and the testing rates among pregnant women the annual hivaids statistics therein are sourced from the hivaids confirmation files received from the regional centers for the evaluation and monitoring of hivaids these files are then processed by the department for monitoring and evaluation of hivaids in romania which belongs to the national institute of infectious diseases prof dr matei balș in bucharest the official reports underscore the challenges that romania still faces in its battle against hivaids emphasizing the gaps in hiv surveillance treatment prevention and testing 109 famous stories since its beginning the hivaids epidemic has permeated all facets of society including the entertainment and sports sectors commendably several personalities had the courage to reveal their hivpositive status thus reshaping societal perspectives and attitudes toward those living with hivaids freddie mercury the iconic lead vocalist of queen made his aids diagnosis public just a day before his demise in 1991 his untimely death brought the ailment to the forefront of global attention and spurred significant fundraising initiatives for aids research in his honor the annual freddie mercury tribute concert for aids awareness has raised substantial amounts for the cause 134 in a similar vein the basketball community was stunned in 1991 when magic johnson announced his hivpositive status which led to his immediate retirement from the nba over the years johnson has ardently advocated for hivaids awareness emphasizing the importance of early detection treatment and the possibility of leading a fulfilling life postdiagnosis 135 additionally olympic gold medalist diver greg louganis in his 1995 autobiography shed light on the discrimination he endured within the sports industry underscoring the persistent stigma tied to hivaids even amongst toptier athletes 136 in 2015 actor charlie sheens public declaration of his hivpositive status sparked widespread discourse about the disease sheens transparency about his diagnosis treatment journey and the challenges he faced such as blackmail attempts highlighted the contemporary issues encountered by those living with hiv even in an era of advanced medical care 137 by sharing their personal journeys these prominent figures have amplified awareness and dispelled many myths associated with hivaids thereby igniting broader societal discussions on the importance of inclusivity and compassion furthermore by living their truths the survivors have inspired countless individuals proving that with the right support and treatment one can lead a prosperous life despite an hiv diagnosis resolutions on the legal front many countries have fortified their frameworks in order to protect the infected from discrimination these laws span various facets of daily life from schooling and housing to employment and healthcare for instance guidelines in many nations explicitly shield individuals living with hivaids from workplace discrimination and several countries have even prohibited mandatory hiv testing for employment 110 entities like government sectors nongovernmental organizations and human rights commissions actively champion the implementation of these laws additionally legal associations extend free services to the issued by the united nations general assembly the 2001 declaration of commitment and the 2006 political declaration represented the collective stance and commitments of the international community toward addressing the epidemic the first resolution recognized hivaids as a global emergency setting out concrete targets to reverse the epidemic by 2015 while the second built upon its predecessor reaffirming previous commitments and setting new targets while including universal access to hiv prevention and treatment by 2010 after providing technical expertise and data during their drafting unaids monitored global progress against the commitments made regularly publishing reports that tracked advancements in combating hivaids furthermore the agency coordinated the efforts of various un entities in the hivaids response ensuring that the promises made in the unga declarations translated into concrete actions on the ground 111 112 113 the 2011 political declaration reviewed the progress made since the previous resolutions noting that despite significant advancements the epidemic remained a major human catastrophe with millions affected the official document commended the efforts of various stakeholders including governments un agencies and civil society in addressing the epidemic and highlighted the importance of international cooperation the role of research and the need for affordable medicines in the fight against hivaids 114 in june 2021 unga adopted a new declaration which committed world leaders to addressing gender inequalities restrictive laws as well as various forms of discrimination in order to halt the global aids epidemic by 2030 the political document received 165 votes in favor with 4 against and no abstentions notable figures including charlize theron a un messenger of peace and yana panfilova a young woman from ukraine living with hiv delivered remarks on the need for change and addressing stigma winnie byanyima the executive director of unaids lauded the declaration as a foundation for renewed global efforts against hivaids amina j mohammed deputy secretarygeneral of the united nations highlighted the central role of unaids in achieving the sustainable development goals and eradicating this public health threat by 2030 the adoption of this declaration thus signifies a renewed global focus on the challenges and barriers in the fight against hivaids 115 116 the romanian government has also made notable strides in its approach to the hivaids epidemic over the years law no 5842002 established on 29th october 2002 and modified as of 1st april 2013 sets forth measures to prevent the spread of aids in romania and safeguard individuals with hiv and aids the law underscores the importance of hiv prevention the fight against aids and the protection of affected individuals it also mandates the promotion of hiv prevention information in educational institutions and ensures medical care antiretroviral treatment and continuous training for medical personnel the law guarantees the rights of hivaids patients to education work and social protection emphasizing that their health status cannot be grounds for dismissal funding for these initiatives comes from various sources including the state budget and the phare community program the law also stresses the confidentiality of hivrelated data with legal consequences for intentional transmission in essence this legislation offers a holistic approach to hivaids prevention treatment and patient rights in romania 117 in addition the national strategy for 20042007 was formulated during a time when romania faced a unique challenge with the epidemic particularly among children largely due to unsafe medical practices in previous years such as unscreened blood transfusions and the repeated use of syringes as a result its primary objectives were to prevent new hiv transmissions and ensure access to treatment and care however romania encountered many challenges during that period such as the limited access to lifesaving antiretroviral drugs and the significant stigmatization and discrimination against hivaids patients additionally there was a pressing need for widespread education and awareness campaigns to inform the public about the disease 118 on the other hand the national strategy for 20222030 was developed in a context where the global understanding of hivaids had significantly advanced with the benefit of better resources medical advancements and a more integrated approach both at the european and global levels this strategy aligns with the unaids 909090 objectives aiming to diagnose 90 of all hivpositive persons provide antiretroviral therapy for 90 of those diagnosed and achieve viral suppression for 90 of those treated a core principle of this official plan is to guarantee equal and continuous access to prevention medical care and social services for those living with hivaids without any form of discrimination nevertheless stigmatization still remains as does the inaccessibility to services especially in the case of vulnerable groups 119 comparing the two strategies both emphasize the importance of preventing hiv transmission combating stigma and discrimination and improving access to treatment and care however the most recent one benefits from a more globalized and integrated approach and places a greater emphasis on human rights and addressing inequalities at present experts in the field of hivaids are calling for the funding and implementation of the national strategy for 20222030 in a debate organized by the unopa federation on june 15 2023 the need to accelerate the funding and implementation of the measures in the strategy was highlighted over 100 experts discussed the steps of the strategy funding sources and priority actions in the field of prevention education testing diagnosis and treatment of hiv in romania senator adrian streinu cercel emphasized the need to find funds and accessible hiv testing for everyone while adriana pistol secretary of state in the ministry of health spoke about the importance of the strategy and the support of the ministry in a similar vein the president of cnas adela cojan mentioned the measures in the new framework contract to be implemented from july 1 2023 while iulian petre executive director of unopa also stressed the importance of funding and implementing the new strategy 120 reports in the global quest to understand the barriers to effective prevention treatment and care several pivotal reports provide insights into the challenges and proposed solutions one such contribution was the 2006 report by the united states agency for international development which explored the feasibility of quantifying the multidimensional nature of hivaidsrelated stigma in developing countries in order to assess interventions and monitor program outcomes 121 similarly the 2003 unaids report from geneva underscored the perpetuation of societal misconceptions about hivaids and advocated public awareness campaigns legal reforms and communitybased interventions 122 during the xvi international aids conference in toronto the unaids executive director dr peter piot called for the development of robust tools and strategies to counter the profound effects of stigma on individuals mental health and healthcare accessibility 123 the 2007 unaids report further emphasized the integration of antidiscrimination measures into national aids initiatives championing communityled initiatives as effective strategies 124 recognizing the gravity of the relationship between stigma notably pronounced among black and latino gay men and the prevalence of sexually transmitted hiv two prominent organizations the national alliance of state and territorial aids directors and the national coalition of std directors embarked on an exhaustive threeyear study their findings culminated in a blueprint comprising several strategic recommendations from promoting advancements in treatment to the importance of adherence to treatments like preexposure prophylaxis 125 regarding romanias hivaids past the 2006 human rights watch report painted a grim picture of the challenges still faced by hivinfected children and adolescents after the crisis in the late 1980s and 1990s despite a significant demographic of hivpositive individuals aged 15 to 19 at the time romania kept grappling with widespread discrimination which affected proper education medical care and employment opportunities the report emphasized the importance of international collaboration and financing to instigate meaningful change in romania and shed light on the breaches of confidentiality regarding hiv status and the legal challenges faced especially by women and girls 126 a recent report offers a thorough examination of the hivaids landscape in romania in the last four decades also touching upon the unaids 909090 targets the document delves into the history of the hiv epidemic in romania from 1985 to 2020 noting a cohort of longterm survivors infected between 1987 and 1990 now aged 2935 the majority of new hiv cases in 2020 were among males with the age groups 2535 and 1524 being the most affected heterosexual transmission was predominant but cases among men who have sex with men and injecting drug users were also notable the current standards of care in romania emphasize universal access to treatment challenges in mothertochild transmission and the rise in new hiv cases among the youth and msm future projections based on data from the burnet instituteoptima hiv indicate that romania with its current budget and strategies is on a path to achieve significant reductions in hiv incidence and mortality 127 over the last three years romania has seen a steady increase in the cumulative number of hivaids cases as of the end of 2021 there were 27336 reported cases since 1985 this number slightly increased to 27409 by 1st december 2022 and further to 27436 by the end of that year by 30th june 2023 the cumulative cases reached 27465 the number of new cases detected each year has varied with 318 new cases in 2021 100 in 2022 and 129 in the first half of 2023 throughout these periods the most common route of hivaids transmission has consistently been heterosexual contact 128 129 130 131 on 1 december 2022 unaids emphasized the theme equalize for world aids day highlighting persistent inequalities that had perpetuated the aids pandemic the equalize campaign called for collective action urging everyone to confront and rectify disparities that hindered progress in eradicating aids unaids advocated for enhancing hiv services reforming laws and policies to combat stigma and promoting technology sharing for equitable access to advanced hiv science data from unaids showed that the global response to hiv had faced challenges over the past two years with significant disparities remaining in accessing basic hiv services activities organized in november 2022 led up to world aids day with events held globally unaids showcased these events through shared photos and videos unaids executive director winnie byanyima emphasized the collective responsibility to address inequalities stating that everyone benefited when tackling these issues 132 133 iv discussion the ramifications of an hivaids diagnosis extend far beyond the immediate physical health concerns this article synthesizes findings from an extensive review of academic and nonacademic literature including famous narratives to shed light on the coping mechanisms of those affected as well as their lived experiences a recurrent theme in all the materials is the persistence of stigma and discrimination and the adjacent range of negative beliefs feelings and attitudes toward individuals living with hivaids according to the literature there are several types of stigma personal where individuals endorse negative beliefs about those with hivaids perceived where the infected feel that society holds negative views about them enacted stigma which involves actual experiences of discrimination due to ones hiv status anticipated stigma which refers to the fear or expectation of facing discrimination or negative reactions in the future because of ones hiv status and internalized or felt stigma where individuals with hivaids accept and internalize the negative beliefs and feelings about themselves all types can manifest in various ways including social ostracization discrimination in healthcare and employment and negative selfworth thus hindering prevention testing and treatment efforts these prejudices usually stem from a lack of comprehensive knowledge about the virus and the disease together with the misconceptions surrounding their transmission a new theoretical model links the structure of aidsrelated stigma to gender as a societal construct underscoring the need to recognize the genderspecific experiences of stigma despite global efforts to ensure institutional support and strategies to combat stigma and discrimination the infected continue to grapple with breaches of confidentiality nonconsensual hiv testing verbal harassment and even denial of treatment within the emotional landscape of an hiv diagnosis individuals often oscillate between feelings of fear sadness and anger with appropriate treatment and support these intense emotions could gradually subside unless societal rejection amplifies these feelings further straining the mental health of the affected all the materials used in this study underscore the indispensable role of support systems in the lives of people living with hivaids support groups thus emerge as vital platforms offering a sanctuary for hivpositive individuals to share experiences express emotions and learn from peers health care providers too are pivotal in this ecosystem as they often serve as the initial point of contact guiding individuals to these support groups and addressing their emotional wellbeing when not succumbing to discriminatory attitudes themselves healthcare providers can recommend a combination of therapies and medications tailored to help individuals navigate emotions like anxiety depression and the associated stigma many of the studies reviewed employed either quantitative or qualitative research methodologies or even a blend of both the dependent variables encapsulated manifestations of stigma and discrimination against plha andor their coping strategies in contrast independent variables encompassed sociodemographic characteristics levels of hiv knowledge training on stigmarelated topics and perceived institutional support quantitative data was usually collected through pretested selfadministered questionnaires telephone or crosssectional surveys or randomized controlled trials and then interpreted using factor analysis ttests pearsons correlation multiple linear regression analyses and other statistical approaches in contrast qualitative data was sourced through keyinformant and semistructured interviews focus group discussions and content analysis of press reports among others several studies have utilized attribution theory as a framework to investigate hivaids stigma and examine how different attributions relate to stigmatizing attitudes and behaviors by understanding these cognitive processes researchers and practitioners can better address and combat the pervasive stigma associated with hivaids the notion of perceived responsibility refers to the fact that individuals contracting the virus through controllable behaviors such as unprotected sex or drug use might face heightened blame and stigma compared to those acquiring it through uncontrollable means like blood transfusions this perceived controllability can lead to discrimination especially if the individual is thought to have had the power to prevent contraction but did not external attributions such as viewing hivaids as a result of moral failings can amplify fear and avoidance behaviors additionally the justworld theory posits that people believe in the inherent fairness of the world so everyone gets what they deserve when applied to studies on hivaidsrelated stigma and discrimination this existential model indicates that the infected are often perceived as deserving of their condition due to presumed moral failings or risky behaviors this belief system can therefore lead to heightened blame and stigmatization as people may think those with hivaids brought the condition upon themselves such perceptions invariably result in discrimination social ostracization and reluctance to support or empathize with affected individuals as society seeks to rationalize the illness as a consequence of personal choices rather than a complex interplay of factors in some of the reviewed studies several frameworks and scales have been employed to understand and measure the multifaceted nature of stigma for instance the hiv provider stigma scale assesses healthcare providers stigmatizing attitudes and behaviors toward hiv patients while the hiv stigma framework delves into the processes and consequences of stigma considering both the experiences of those with hiv and societal perceptions the hiv and abuse related shame inventory gauges the shame associated with hiv especially in the context of past abuse whereas the hivrelated life stressor burden scale measures the cumulative stress experienced by those with hiv encompassing factors like disclosure concerns and treatment issues in a similar vein the chronic illness quality of life model evaluates the impact of hiv as a chronic illness on an individuals quality of life considering both medical and psychosocial dimensions lastly the people living with hiv stigma index as a v coping summary while there have been significant advancements in understanding and treating hivaids the shadows of stigma and discrimination still loom large hence the persistence of the suicidal risk especially when disclosing ones hiv status thus addressing these issues not only upholds human rights but also promotes respect and understanding for those affected the adaptive mechanisms elucidated in this paper buttressed by institutional support and legal safeguards can assist plha in their individual and collective journeys advocating a more inclusive and empathetic society according to the studies used therein those who rely on disengagement and feel heightened stigma often show increased anxiety and depression levels in contrast those using engagement control techniques exhibit a diverse range of coping strategies communication plays a crucial role in dispelling myths about hivaids and reducing discriminatory views innovative prevention methods include culturally tailored interventions educational initiatives and even purposive choreography an informed individual can make better health decisions and even educate others furthermore group interventions can assist hivpositive individuals in dealing with aidsrelated bereavement open dialogues about feelings and experiences with trusted individuals will help build a strong networking system that can include friends family and healthcare providers moreover a strengthsbased approach can enhance ones perception of social support especially in the case of older adults some studies also emphasize the importance of a gender perspective in aids prevention programs along with the crucial role healthcare providers play in the disclosure process commendably support groups and peer counseling offer platforms for sharing stories in order to reduce negative feelings in some cases however hivassociated neurocognitive disorders can become so severe that the infected may require medical intervention as well as a frequent record of the symptoms for a more personalized approach professional counseling and therapy can provide invaluable guidance on recognizing and avoiding stressinducing situations as well as practicing adequate selfcare in a holistic manner relaxation techniques like meditation yoga and deep breathing combined with faithbased strategies and even crying spells can help release builtup tension manage stress and promote wellbeing moreover engaging in physical activities ensuring adequate rest maintaining a balanced diet and moderating caffeine and nicotine intake can serve as proper outlets for stress and anger additionally awareness campaigns can challenge cultural norms and promote empathy so engaging the community while implementing policy interventions can create a more inclusive environment furthermore the infected celebrities that have shared their stories have implicitly transformed their personal challenges into powerful advocacy platforms underscoring the essence of human resilience and the critical need for empathy and acceptance more specifically some studies have utilized a range of tools to delve into the challenges confronted by individuals with the virus the ways of coping checklist evaluates strategies that individuals employ when they encounter stressful events the coping strategies inventory measures the different ways individuals manage and respond to stress providing insights into both effective and maladaptive coping mechanisms another significant tool living in the face of trauma seeks to bolster coping skills for women with hiv last but not least the cognitivebehavioral bereavement coping group intervention introduces groupbased approaches to tackle hivaids stigma and discrimination in summation while societal transformation remains a longterm goal people with hivaids can use various tools and strategies to face their challenges through a comparative analysis across diverse materials the current research underscores the detrimental effects of coping behaviors like distraction resignation avoidance defensiveness aggressiveness solitude and isolation as they can exacerbate distress mood disturbances and societal perceptions potentially leading to depression and even suicide conversely strategies such as positive involvement information seeking reliance on others and positive understanding have been shown to mitigate mood disturbances and bolster selfesteem the research thus emphasizes the importance of awareness campaigns tailored and culturally sensitive interventions community engagement as well as understanding the relationship between stigma cultural norms and societal attitudes in the end coping strategies should leverage the resilience of stigmatized communities to bring about societal change vi limitations the current study while comprehensive in its approach has certain limitations firstly the reliance on literature review as the primary method might not capture the full breadth of personal experiences direct interviews or surveys with affected individuals could have provided more nuanced insights secondly the studys focus on literature available in online databases and referenced books might have inadvertently excluded valuable grassroots reports or firsthand accounts not available in mainstream publications this limitation could lead to potential biases in the representation of lived experiences additionally the studys emphasis on coping derived from the literature might not encompass all the coping mechanisms employed by individuals in diverse cultural and socioeconomic contexts the strategies discussed therein might therefore reflect a bias toward those documented in academic and official reports potentially vii future research the diverse nature of the hivaids experience across the globe necessitates more localized and contextspecific studies first and foremost there is still a palpable need for research on the development and implementation of positive coping mechanisms while this study has highlighted several effective strategies there remains a vast expanse of uncharted territory future research could delve into the nuances of these strategies exploring their applicability across diverse cultural socioeconomic and demographic contexts for instance how do these strategies manifest in rural settings as compared to urban environments or how do they resonate with different age groups especially the younger generation who might be grappling with the dual challenges of adolescence and an hiv diagnosis additionally there is a pressing need to study the longterm efficacy of these coping mechanisms while some might offer immediate relief their longterm implications remain largely unexplored future research could therefore focus on longitudinal studies that track the mental and emotional wellbeing of individuals over extended periods providing insights into the sustainability of these coping mechanisms another pivotal area of exploration is the continued role of societal structures in fostering an inclusive and empathetic environment while individual coping mechanisms are crucial societal acceptance and support can significantly amplify their effectiveness future studies could thus delve deeper into the role of educational institutions workplaces healthcare systems and even media in shaping societal perceptions about hivaids what sustainable interventions can be implemented at these institutional levels to foster a more inclusive environment how can curriculums be modified to include comprehensive hivaids education dispelling myths and fostering empathy furthermore the advent of advanced technology represents a great opportunity to explore digital interventions how can technology be leveraged to provide support to those living with hivaids could virtual support groups teletherapy or even aidriven interventions offer better solace and guidance lastly while this study has drawn extensively from academic and nonacademic literature there is still a wealth of knowledge embedded in personal narratives grassroots organizations and communitydriven initiatives future research could therefore adopt a more participatory approach tapping into the voices experiences and insights of those living with hivaids ultimately while this comprehensive study provides a foundational understanding of the coping mechanisms the infected employ in the face of stigma and discrimination it only represents a stepping stone the path ahead is still rife with research opportunities that can deepen the present understanding of hivaids phenomenon while paving the way for tangible impactful interventions to foster a world where the infected are embraced with empathy and respect quantum solution the world of quantum computing seen as a groundbreaking technological evolution offers immense potential for various fields with medicine standing out as a particularly anticipated beneficiary quantum computing draws its foundation from quantum mechanics principles enabling the processing of vast information simultaneously in contrast to traditional computers which rely on binary bits and therefore face limitations in handling complex problems quantum computers use qubits which have the ability to exist in several states simultaneously and can therefore execute intricate calculations at speeds never seen before 138 in the hope of addressing complex diseases such as hivaids the capabilities of quantum technologies could thus reveal previously unthoughtof solutions drug discovery and development still present a significant challenge in hivaids research so the goal remains to find effective drugs that target the virus without causing harsh side effects as quantum computers with their unmatched computational power can emulate the detailed interactions between molecules proteins and viruses they can dramatically shorten drug discovery timelines thus enabling researchers to sift through numerous molecular combinations and pinpoint potential drug candidates with greater accuracy hivaids has genetic factors that influence its progression and how the body responds to treatments quantum computing could therefore expedite the analysis of extensive genomic datasets pinpointing patterns and mutations crucial for a deeper understanding of the disease and customizing treatments based on individual genetic makeups moreover given the viruss ability to mutate and adapt quantum computers could aid in developing predictive models that consider these mutations equipping healthcare professionals to anticipate changes and modify treatment plans as needed beyond just computing the wider range of quantum technologies including quantum sensing and communication holds the potential to transform diagnostics and the security of patient data for instance quantum sensors viii conclusion from its emergence to the present the hivaids epidemic has exposed deepseated societal prejudices and misconceptions beyond its medical implications so the disease will always stand as a testament to humanitys capacity for both cruelty and compassion facing an hiv diagnosis invariably triggers a spectrum of emotions from sadness and denial to fear and depression hence the vital importance of open communication discussing feelings with health care providers trusted friends or support groups can therefore foster understanding and empathy knowledge about hiv can also alleviate the feelings of fear and anxiety while engaging with support groups or volunteering at hiv service organizations can empower both the infected and those who really want to help however while some strategies apply universally others are deeply personal shaped by individual experiences cultural contexts and societal norms together in order for the infected to seek proper treatments and surround themselves with supportive individuals societal change remains paramount as the world moves forward the pressing need for collective introspection and action grows stronger governments institutions communities and individuals must therefore remain united to create a stronger global environment where acceptance supersedes the multifaceted and everevolving nature of stigma and discrimination associated with hivaids this paper delved into the complexities of living with hivaids aiming to offer holistic insights for future interventions and research the review process involved a comprehensive search across several medical and healthrelated databases in order to identify relevant articles studies and other materials about coping with hivaidsrelated stigma and discrimination after screening the identified literature the study extracted relevant data and insights into coping strategies personal experiences as well as the impact of stigma and discrimination given the significant variation in the sources in terms of context methodology and focus the research ultimately offered a narrative summary of the findings thus by conducting a rigorous literature review from an empathizers perspective the paper seeks to deepen the understanding of stigma and discrimination against individuals with hivaids while revealing a range of effective coping strategies mihas story serves as a poignant reminder of the human faces behind the statistics her resilience against overwhelming prejudices reflects the strength and tenacity of countless others like her the dream she nurtured of creating a venture to support stray animals symbolizes the aspirations of many living with hivaids to lead lives filled with purpose dignity and acceptance ultimately this tribute to miha serves as a plea for empathy understanding and collective responsibility with concerted efforts informed interventions and a shared vision of an inclusive world a more compassionate future indeed seems possible integrated journal for annex the subsequent survey is a product of all the materials employed in this research it could therefore hold promise for future investigations into the validation and application of hivaidsrelated stigma and discrimination hivaids

stigma and discrimination have a profound psychological and societal impact on individuals living with hivaids and their communities this research offers an indepth exploration of these challenges drawing insights from a vast array of sources such as articles books films documentaries websites reports resolutions and famous stories in order to provide valuable insights into building resilience and fostering supportive environments the study simultaneously examines the coping mechanisms and strategies employed by the infected as depicted in the literature used therein the example of miha a young woman who faced societal biases despite her achievements serves as a poignant reminder of the many sad narratives behind the statistics this paper ultimately emphasizes the urgent need for continued efforts in awareness education and advocacy of combating hivaidsrelated stigma and discrimination and culminates in a call for collective action empathy and a shared vision of an inclusive world

impairment in later life the purpose of this article is to extend this line of research by testing the rehabilitative potential of social relationships for functional health recovery among older adults specifically we test whether social relationships serve as facilitators of recovery from severe mobility limitation the loss of mobility is an important predictor of disability onset institutionalization and premature mortality prior research has emphasized the benefits of social relationships for preventing functional health declines yet research exploring the link between social relationships and recovery from functional impairment has typically been more limited previous research on disease management and postsurgical recovery in relation to social relationships suggests the rehabilitative potential of social relationships for example a large body of empirical evidence links positive social relationships to better functional health outcomes among stroke patients while these and other similar studies provide evidence for the significance of social relationships for recovery most rely on clinical data and are often limited in scope and may represent homogenous populations moreover measured sources of support are almost exclusively spousal adult child andor healthcare professional neglecting the importance of peer relationships for health clinical studies also frequently overlook the gendered nature of older adults social relationships a limitation addressed by this analysis this research aims to broaden the current social relationship and recovery literature by examining multiple sources of social support among a national sample of older americans and testing whether gender moderates the effect of social relationships on recovery from severe mobility limitation the aspects of social relationships that are protective for maintaining mobility in later life may continue to play a role in recovery from mobility limitation indeed social relationships may become more salient for those who have experienced a serious health decline or loss of independence social relationships and health the term social relationships often refers to multiple distinct features of social connection offered by relationships including social integration quality of relationships and network structures cohen underwood and gottlieb conceptualize social relationships as influencing health via two main processes social support and social participation social support refers to the specific supportive actions performed by network members such as the provision of emotional or financial support cohen et al highlight the importance of exchange when defining social support social participation shapes health status through participation in social groups by influencing cognitions emotions behaviors and biological responses and is differentiated from social support by its emphasis on social connections rather than exchange of resources within the processes of social support and social participation there are numerous underlying mechanisms linking social relationships to better health broadly classified as psychosocial and behavioral mechanisms within the psychosocial framework social relationships are typically viewed as a stress buffer social relationships may mitigate stressful events through social exchange social comparison or personal control while psychosocial mechanisms may refer to aspects of mental health such as emotional responses or the role of symbolic meanings and norms behavioral explanations emphasize the influence of social relationships on the participation in health behaviors such diet and physical activity as well as healthcare utilization social support and social participation often occur simultaneously therefore it is difficult to isolate the specific explanatory factors for each process however it is clear that social relationships have the capacity to influence psychosocial and behavioral reactions via social support and participation which in turn influences health social relationships gender and physical health among older adults most research examining social relationships in later life underscores the role of family previous empirical research has noted the predominance of family within the social networks of older adults in particular prior research suggests that spouses and adult children are key members of the elderlys social network although family members are essential members of older adults social networks friends and neighbors are also valuable sources of social support previous research demonstrates a preference among the elderly to receive social support from friends or neighbors rather than family additionally a study exploring social participation and mortality among older adults observed an increase in rates of survival among respondents who spent time with friends this association was not found for other types of social contact including time spent with spouse or family after adjusting for numerous demographic and health covariates maier klumb research suggests that time spent with friends was more important for survival than other types of social contact according to gallant spitze and prohaska among older adults managing a chronic illness social support from friends has fewer negative influences than family members likewise compared with family members friends of older adults with chronic illness are more important for the provision of emotional and informational support and participating in healthpromoting management behavior while family members may provide various kinds of social support previous research suggests that family members are the primary suppliers of instrumental support whereas friendships appear to benefit health mainly through emotional and information support there are important gender differences in composition and effect of older adults social networks older women generally have larger social networks while older men tend to have smaller networks with their wives occupying a central role to illustrate wives are much less likely to select their husband as a primary caregiver while undergoing cancer treatments in general the presence of family members and positive social support in an older individuals social network confers physical health advantages for both men and women yet men and women may experience differing levels of health benefits from filial support not only are men more likely to be partnered in later life but these partnerships appear to be more advantageous for mens health partly due to wives emotional responsiveness and enactment of greater social control of mens health behaviors furthermore regarding functional health specifically older men may derive greater benefit from more social ties than older women thus while older women tend to have larger and more diverse social networks current research suggests that men acquire more health benefits from social relationships particularly from their partners linking social relationships to recovery from mobility limitation compared with other functional health outcomes social relationships may be equally or even more important for recovery from mobility limitation defined as the ability to move about independently in ones environment and a critical link in the pathway to onset of disability in tasks essential to independent living for example emotional social support may become more relevant as a stress buffer during a health shock resulting in a loss of mobility social participation may also become more relevant due to the benefits to mobility afforded by the increased physical activity associated with engagement in order to capture multiple aspects of social relationships we identified variables that approximate familial social network instrumental social support neighborhood engagement and embeddedness and community engagement the familial social network describes the availability of family members including whether an individual is partnered has adult living children living siblings or relatives living nearby family members are a critical source of instrumental support so the composition of ones familial social network may be significant for older adults ability to recover from mobility limitation while receiving instrumental support has potential health benefits it may also lead to poorer functional health because those who receive assistance may become overly dependent on caregivers and lose the ability to independently carry out daily activities the familial social network measures test whether the presence of family members shape recovery outcomes however we also use two specific measures of instrumental support to explore whether giving or receiving impacts recovery outcomes financial instrumental support may be associated with recovery from mobility limitations since those receiving instrumental support may have more resources to modify their environment or manage their underlying condition alternatively receiving financial support may cause distress due to negative emotions associated with receiving support versus giving support providing instrumental support may also influence recovery because it is associated with positive emotions and increased confidence neighborhood engagement and embeddedness refers to whether a person visits or feels close to their neighbors neighborhood engagement is indicative of an individual being active and involved within their neighborhood while neighborhood embeddedness is indicative of social connectedness finally community engagement may also signify involvement frequent contact with neighbors is associated with a greater sense of community and individual wellbeing which positively influences health despite having a mobility limitation individuals who are involved in their neighborhoods and communities may experience better functional health outcomes because their involvement encourages physical activity outside of the home simonsick guralnik volpato balfour and fried emphasize the importance of just getting out the door for older womens functional health status the authors observed protective effects from regular walking among functionally impaired older women among older adults who are socially engaged not only they are encouraged to leave their homes thus contributing to positive mobility they may also benefit from the resources associated with being embedded in their neighborhoods and communities such as emotional informational and instrumental social support to illustrate pilkington windsor and crisp found that higher reports of positive subjective wellbeing among older individuals who volunteer is related to more extensive social networks taken together the extant literature reveals the potential for social relationships to positively influence functional health outcomes including recovery however not all facets of social relationships may be positive such as receiving instrumental support additionally the social networks of older adults are often gendered and the health benefits from positive social relationships appears to vary by gender with men experiencing greater health advantages from being partnered much of the previous research exploring recovery from functional impairment does not address the importance of friends and neighbors and neglects gender differences in social relationships this research attempts to address these gaps by examining recovery from severe mobility limitation using data from a nationally representative sample of older americans we utilize multiple measures of social relationships from a variety of sources and investigate whether social relationships and recovery is moderated by gender methods data data for this research come from the health and retirement study an ongoing nationally representative panel study of an american cohort born in 19311941 the hrs is sponsored by the national institute of aging and is conducted by the institute for social research at the university of michigan at baseline facetoface interviews were conducted for hrs respondents and their spouses regardless of the spouses age followup interviews have been conducted via telephone every 2 years since baseline in 1998 the hrs merged with another ongoing survey the asset and health dynamics among the oldest old which consisted of respondents born in 1923 or before additionally two more cohorts were added in 1998 the war baby cohort and the children of the great depression the sample size in 1998 including all four cohorts was 21384 the hrs employs a multistage clustered probability frame and oversamples blacks african americans hispanicslatino and florida residents the 1998 response rate was 883 and the response rate for subsequent waves ranged from 876 to 889 for all cohorts analyses are based on the rand hrs data file a userfriendly longitudinal data set created from original hrs data by the national institute on aging and the social security administration the rand data file maximizes crosswave concordance of variables to facilitate longitudinal analyses including the careful imputation of missing data the sample for this study includes all respondents and spouses who were over the age of 50 years in 1998 with valid data for the mobility and social relationship measures we follow these respondents to 2008 using event history analysis to examine the factors influencing recovery from mobility limitations across each 2year interval measures dependent variables severe mobility limitation recovery from severe mobility limitation was measured using selfreports of walking difficulty there are three measures of difficulty walking available in the hrs which reflect varying distances and levels of strain difficulty walking several blocks difficulty walking one block difficulty walking across the room these measures can be conceptualized as hierarchal indicators of mobility limitation where difficulty walking shorter distances is indicative of greater walking impairment respondents were considered to have severe mobility limitation if they reported difficulty walking across the room or one block we conceptualized recovery from severe mobility limitation as either complete recovery or partial recovery risk group the risk group for these analyses was respondents with severe mobility limitation because of the dynamic nature of mobility limitation onset and recovery the risk group was refreshed at the beginning of each interval in 1998 the atrisk sample included 2722 respondents the subsequent atrisk samples from 2000 to 2008 ranged from 2321 to 2515 respondents outcome variables the analytic strategy for this research utilized event history analysis with multiple competing events the outcome variables of interest were complete recovery from severe mobility limitation and partial recovery from severe mobility limitation in addition to the two recovery outcome variables mortality and attrition were included as competing outcomes the findings for these outcomes are not presented but are available from the authors upon request persistent severe mobility limitation was the reference outcome variable all outcome variables were compared with persistent severe mobility limitation independent variables social relationships social relationships were the independent variables of interest we attempted to include as many domains of social relationships as possible using the measures available in the hrs from 1998 to 2008 all measures of social relationships were treated as timevarying as a group the social relationship measures represent familial social network engagement and embeddedness and instrumental support familial social network was comprised of four measures partnered status number of living children number of living siblings and relatives residing nearby a dichotomous measure of marriedpartnered status was created where partnered 1 the number of living children and living siblings were treated as continuous measures respondents who reported having relatives living in the neighborhood were considered to have relatives residing nearby neighborhood engagement and embeddedness as well as community engagement were included in the analyses neighborhood engagement was constructed from one question how often do you get together with any of your neighbors just to chat or for a social visit likewise neighborhood embeddedness was constructed from one question do you have any good friends living in your neighborhood because of concordance issues the neighborhood engagement measure was collapsed into a dichotomous variable where any visitation with neighbors 1 similarly the neighborhood embeddedness was coded dichotomously where having good friends in the neighborhood 1 whether a respondent volunteered was employed as a community engagement measure and a dichotomous variable was created from have you spent any time in the past 12 months doing volunteer work for religious educational healthrelated or other charitable organizations two measures of instrumental support were created from two questions which reflect given and received instrumental support a dichotomous measure of given social support was created from the item have you spent any time in the past 12 months helping friends neighbors or relatives who did not live with you and did not pay you for the help similarly a dichotomous measure of received social support was created from did you or your husbandwifepartner receive financial help totaling 500 or more in the last 2 years from friends or relatives unfortunately the given and received measures do not assess the same form of instrumental support there was not a comparable measure of financial support across all waves to use for given instrumental support and vice versa for the helping measure sociodemographic characteristics sociodemographic characteristics and health risk factors were included in the analyses as control variables timefixed measures included gender raceethnicity educational attainment and age groups at baseline while income and proxy status were treated as timevarying a dichotomous dummy variable was created for gender where female 1 three dummy variables capture raceethnicity comparing white with blackafrican american latinohispanic and other race a three category measure of education was created based on credential achievement less than high school high school and more than high school age was assessed at baseline and then a categorical measure was created where 5159 years 6069 years 7079 years and 80 years were the age categories household income was measured using quartiles with the bottom quartile used as the reference quartiles were created for each wave using the full sample additionally a dichotomous indicator of whether proxy interviews were used was created where yes 1 health risk factors all health risk factors were treated as timevarying and included measures of health behaviors healthcare access and healthcare utilization two health behaviors were included in the analysis smoking status and body mass index smoking status was measured as a threecategory variable with never smoked former smoker and current smoker as the categories a categorical measure of bmi was constructed from selfreported weight and height measures the categories were based established guidelines and included underweight healthy weight overweight and obese a trichotomous measure for health insurance was created where respondents with either individual or spousal private insurance government insurance or no insurance coverage were the categories health insurance coverage was measured as a timevarying variable healthcare utilization included doctor visits hospitalizations outpatient surgery regularly taking medication and nursing home stays all healthcare utilization measures were asked about the past 2 years a dichotomous measure was created for each healthcare utilization indicator where utilization in the past 2 years 1 morbidity status two measures were employed to assess morbidity status including the number of chronic conditions and selfrated health a count of chronic conditions was used the chronic conditions were based on physiciandiagnosed selfreports selfrated health was measured continuously on a fivepoint likert scale with 1 poor health and 5 excellent health analytic strategy to assess the effect of social relationships on recovery outcomes we employed discretetime event history analysis with multiple competing events which was estimated using multinomial logistic regression this approach is also called the multinomial logit model of competing eventsrisks our models do not assume a particular shape of the hazard function but do assume that the effects of the covariates on the hazard function are the same across all time points our modeling strategy is a type of survival analysis characterized by its handling of time as a discrete variable rather than as a continuous variable with a specified time hazard function with six waves of data collected biennially we have up to five 2year intervals for each respondent the risk group at the beginning of each interval included respondents with severe mobility limitation and possible outcomes at 2year followup included severe mobility limitation complete recovery partial recovery death and attrition although death and attrition are explicitly modeled as a competing event they are not the focus of this analysis therefore the results are not presented because respondents could contribute multiple observations over the observation period which increases the sample size and potentially deflates standard errors we employed robust standard errors to adjust for clustering within persons log odds and odds ratio estimates were ascertained for each independent variable the analyses were left unweighted because many of the attributes for which the weights are calculated are included in the analysis and prior research has suggested that unweighted hrs data is less biased however our analyses using weighted data yielded a similar pattern of results because this research was interested in the specific association between social relationships and recovery from severe mobility limitation numerous controls were employed controlling for sociodemographic characteristics health risk factors and morbidity status gives increased confidence that any positive effect of social relationships is attributable to the mechanisms associated with social relationships and health and not selection based on socioeconomic status and health additionally because prior literature has suggested that men and women have differing social relationships in older ages we tested gender and social relationship interactions for each social relationship measure results descriptive statistics table 1 displays the descriptive statistics the initial risk group by gender nearly twothirds of the total sample was women among the social relationship variables relative to men fewer women were partnered and engaged at baseline additionally women received more instrumental support in the form of financial assistance and gave less instrumental support in the form of unpaid help in prior research older women are often described as being more engaged and having more social ties however in our initial risk group of older adults with severe mobility limitation it is men who appear to have more engagement within the neighborhood furthermore women in the initial risk group were older and poorer than men in general comparing the total sample with the original sample of all respondents over the age of 50 in 1998 the initial risk group was comprised of respondents with fewer social relationships lower ses more healthcare utilization and poorer morbidity status discretetime event history with multiple competing events main effects models table 2 presents findings obtained from multinomial logistic regression analysis for complete recovery and partial recovery versus persistent severe mobility limitation by social relationships sociodemographic characteristics health risk factors and morbidity status log odds estimates and odds ratios are presented the analytic sample consisted of 11322 personintervals to assess goodnessoffit a likelihoodratio statistic was generated comparing the unadjusted model to the intercept only model as well as the comparing the fully adjusted model to the unadjusted model the likelihoodratio statistics provide strong evidence of overall goodness of fit for both the unadjusted and fully adjusted models five observational intervals were generated from six waves of data approximately 7 of atrisk respondents experienced transitions from severe to no mobility limitation our measure of complete recovery while about 12 of atrisk respondents experienced transitions from severe to mild limitation which we define as partial recovery additionally 20 of atrisk respondents died and approximately 9 attrited during the observational period complete recovery versus persistent severe mobility limitation in model 1 social relationships were included in the analysis without controls therefore model 1 represents the unadjusted risk of recovery by social relationships several measures of social relationships were significantly associated with complete recovery in the unadjusted model partnered respondents 160 were more likely to experience complete recovery than single respondents having more living siblings was associated with greater unadjusted odds of complete recovery respondents living near relatives had lower unadjusted odds of complete recovery community engagement and giving instrumental support were both associated with greater unadjusted odds of complete recovery after fully adjusting for sociodemographic characteristic health risk factors and morbidity status partnered status number of siblings and community engagement were no longer associated with complete recovery however having relatives residing nearby remained significantly associated with lower odds of complete recovery similarly giving instrumental social support continued to be linked to greater odds of complete recovery among sociodemographic characteristics gender raceethnicity age and income were associated with complete recovery women had lower odds of complete recovery relative to men compared with whites black and latinohispanic respondents were more likely to experience complete recovery older ages were negatively associated with complete recovery with the oldest age group having a 60 reduction in the odds of recovery compared with the youngest age group higher household incomes were associated with greater odds of recovery more specifically being in the upper income quartile compared with the bottom quartile was associated with increased odds of complete recovery additionally respondents with proxy interviews had lower odds of complete recovery many health risk factors were significantly associated with complete recovery current smokers as well as underweight and obese respondents were less likely to experience complete recovery from severe mobility limitation government health insurance relative to private health insurance was also linked to lower odds of recovery nursing home stays was associated with diminished odds of complete recovery whereas outpatient surgery was associated with increased odds additionally more chronic conditions were associated with lower odds of recovery while better ratings of selfrated health were associated with greater odds partial recovery versus persistent severe mobility limitation in the right panel of table 2 the unadjusted model indicated that several social relationships measures were significantly associated with partial recovery including partner status the number of living siblings neighborhood engagement community engagement and giving instrumental support being partnered and having more siblings were associated with greater odds of partial recovery being engaged whether in the neighborhood or community was positively associated with partial recovery from severe mobility limitations giving instrumental support was also linked to improved odds of partial recovery in the fully adjusted model neighborhood engagement and giving instrumental support remained significant predictors of partial recovery among the sociodemographic characteristics gender raceethnicity age and household income were linked to partial recovery women were less likely to experience partial recovery relative to men latinohispanic respondents were more likely to recover compared with white respondents compared with the youngest age group the oldest age group had lower odds of partial recovery being in the bottommiddle income quartile relative to the bottom quartile was also linked to greater odds of partial recovery respondents with proxy interviews had reduced odds of partial recovery among health risk factors underweight and obese respondents were less likely experience partial recovery having government insurance compared with private insurance was linked to lower odds of recovery nursing home stays were also negatively associated with partial recovery both morbidity measures were significantly associated with partial recovery having more chronic conditions was negatively associated with partial recovery whereas better selfrated health was positively associated with partial recovery gender interaction effects figures 13 present the predicted probabilities for the significant gender and social relationship interactions for complete and partial recovery predicted probabilities were generated based on the interaction effects models the interaction effects models are available online figure 1 illustrates the predicted probabilities of complete recovery by gender and partner status compared with partnered women partnered men were more likely to experience complete recovery partnered men had nearly three times greater predicted probability of complete recovery relative to partnered women additionally single men were more likely to experience complete recovery relative to single women similar to complete recovery the interaction between gender and partner status was significant figure 2 illustrates the predicted probabilities for partial recovery by gender and partner status again partnered men were more likely to experience partial recovery relative to partnered women finally an interaction between gender and neighborhood engagement was modeled the interaction was significant and the predicted probabilities demonstrate gender differences by neighborhood engagement for partial recovery engaged men were more likely to experience partial recovery compared with engaged women additionally disengaged men were more likely to experience partial recovery compared with disengaged women notably disengaged women were the least likely to experience partial recovery compared with any group discussion results from the foregoing analysis suggest that social relationships serve as facilitators of recovery from severe mobility limitation and that the influence of social relationships varies by outcome and recovery type for complete recovery giving instrumental support was one of the most robust social relationship predictors net of sociodemographic characteristics health risk factors and morbidity status respondents who gave instrumental support had about a 45 increase in the odds of complete recovery in the next 2year period another robust predictor of complete recovery was whether relatives resided nearby respondents living in the same neighborhood as relatives had about a 20 decrease in the odds of complete recovery controlling for all other risk factors there were also two robust predictors of partial recovery neighborhood engagement and giving instrumental support both social relationship measures were positively associated with partial recovery engaged respondents relative to disengaged respondents had approximately a 20 increase in the odds of partial recovery whereas respondents who had given instrumental support had approximately a 34 increase in the odds of partial recovery we also explored whether there were any gendered interactions among social relationships and recovery for both complete and partial recovery partner status was moderated by gender in both cases partnered men were more likely to recover than partnered women for partial recovery neighborhood engagement was also moderated by gender where engaged men were more likely to experience recovery than engaged women furthermore it appeared that disengaged women were the least likely to experience partial recovery giving instrumental support to friends neighbors or relatives appears to be valuable for recovery outcomes despite having severe mobility limitation those respondents who helped their friends and family were more likely to experience complete or partial recovery prior research suggests that providing social support is more beneficial to health among older adults than receiving social support providing support is linked to positive feelings greater sense of control and selfesteem which positively influences health for example providing social support lowers levels depressive symptomology among older adults additionally the residual effects of increased feelings of selfefficacy associated with providing instrumental support may spillover to other beneficial health behaviors which could improve recovery outcomes another positive predictor of recovery was neighborhood engagement respondents who reported visiting friends and neighbors were more likely to experience partial recovery visiting with neighbors suggests that individuals are leaving their home despite their mobility limitations being engaged and active within ones neighborhood may be an important pathway for partial recovery not only do these individuals benefit from the emotional and informational support of companionship they may also be benefitting from just getting out the door where even small amounts of walking helps maintain mobility older adults who are disengaged and more socially isolated are less likely to leave the home which negatively impacts functional health the only social relationship measure to be negatively associated with recovery was having relatives living nearby while this data cannot explicitly speak to the mechanisms linking family proximity to worse recovery outcomes it is possible to gain insight from prior research this association may stem from neighboring relatives providing instrumental support and reducing chances to complete tasks that encourage greater mobility and functional health mendes de leon et al observed increased disability risk among individuals who received instrumental support and attributed this finding to the process of deconditioning whereby individuals who received assistance with daily activities gradually lose the physical capacity to complete these tasks alone in addition mendes de leon et al suggested that receiving instrumental support could weaken a persons selfefficacy and generate a sense of dependency upon others while neighboring relatives may provide important social support opportunities for aging family members with functional impairment it is possible that an overdependence on assistance from nearby family members could arise and have negative consequences for functional health and recovery an alternative explanation may be that individuals who have families who reside in close proximity have worse health trajectories however given the numerous health and morbidity controls we contend that deconditioning may be a more fitting interpretation of these results nevertheless it is possible that both explanations contribute to this finding these findings also highlight important gender differences among social relationships in relation to mobility limitation recovery in general partnered men were more likely to experience recovery than partnered women previous research has noted that marriagepartnership may be more advantageous for mens health than womens health furthermore prior research has suggested that older men and womens sources of support are different with men relying more heavily on their spouse and women relying on multiple sources including friends this research suggests that the health benefits that partnership confers to men may extend to recovery outcomes additionally the positive effect of neighborhood engagement on partial recovery was moderated by gender in general it appeared that disengaged women were the most disadvantaged group regarding partial recovery disengagement and greater social isolation may be particularly deleterious for older womens functional health because older women tend to have more diverse social networks including a greater reliance on friends relative to men a lack of neighborhood engagement among women may have larger implications for recovery from mobility limitation previous research suggests that social support from friends is one of the best predictors of physical activity among older women therefore the absence of neighborhood engagement among older women may be indicative of fewer opportunities for health promoting gettogethers that include exchanges of emotional and information support as well as lower participation in physical activities strengths and limitations this study benefitted from the use of repeated measures of function and social relationships collected prospectively over a 10year period an additional strength of this research was using measures that represented social relationships from multiple sources such as friends and neighbors in order to address potential endogeneity in the temporal sequence between social relationships and recovery we modeled the social relationship measures in all those atrisk for recovery at the beginning of each time interval and recovery by the end of each 2year period this modeling strategy is advantageous because social relationships were assessed during the period of mobility impairment and then recovery outcomes were assessed 2 years later which minimizes concerns about reverse causality individuals who experience functional health declines often encounter a negative impact on their social relationships however our modeling strategy measures current social relationships after functional impairment onset has occurred a potential limitation with this strategy is that it was possible for respondents to have recovered multiple times thus contributing to the study multiple observations of recovery however only a small proportion of respondents who recovered experience multiple recovery episodes supplementary analyses were completed omitting respondents with multiple recovery episodes and the substantive findings remained unchanged additionally our mobility limitation and recovery measures were based on selfreports which may be subject to reporting error while performancebased measures of recovery would have been preferred there is a wealth of research using the hrs selfreported functional health measures which documents the reliability of these measures another limitation stems from restricted social relationship measures the hrs is superior for longitudinal investigation of health outcomes among older adults however we were limited by the social relationship questions available across multiple waves finally it is possible that respondents who maintain certain social relationships despite severe mobility limitation may be unique or have unique social networks however numerous controls were included in the analysis and according to descriptive statistics the majority of the atrisk sample was engaged and embedded although this research has key limitations it still provides evidence that social relationships hold the potential to facilitate recovery from functional impairment conclusion this research may speak to interventions aimed at promoting mobility and functional health within individuals communities helping friends and neighbors was a robust predictor of complete and partial recovery interventions aimed at encouraging community members with functional impairment to provide instrumental support to peers may improve functional health outcomes increased opportunities for proving instrumental support through the use of community services and programs may bolster the health of the provider recipient and community at large to illustrate peer or mutual support programs have had success for various diseasecondition management interventions promoting neighborhood engagement despite severe mobility limitation may be another fruitful avenue for targeted interventions more research is needed to explain variations in the effect of neighborhood engagement on partial recovery by gender however this research suggests that disengaged women may be a particularly vulnerable group for worse functional health outcomes disengaged women may benefit from directed interventions aimed at functional health promotion when considering social relationships and health the type of social relationship measures and the type of health outcome may have differing underlying mechanisms this research reiterates the complexity surrounding social relationships and health it is not simply that all social relationships benefit healthmost may be positive but some may be negative and as this research demonstrates some social relationship measures may be more important for recovery we encourage future researchers to examine different and more nuanced measures of social relationships in relation to both functional health declines and recovery in particular we recommend future research investigating perceived social support and other measures of social relationships in relation to recovery with the aim to undercover the specific mechanisms linking social relationships to mobility limitation recovery we also urge researchers and clinicians to develop interventions aimed at facilitating recovery from functional health declines through social relationships supplementary material supplementary material can be found at

objectives evidence suggests social relationships may be important facilitators for recovery from functional impairment but the extant literature is limited in its measurement of social relationships including an over emphasis on filial social support and a paucity of nationally representative data methods using data from waves 49 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 of the health and retirement study hrs this research examines the association between social relationships and recovery from severe mobility limitation ie difficulty walking one block or across the room among older americans using a more nuanced measure of recovery that includes complete and partial recovery a series of discretetime event history models with multiple competing recovery outcomes were estimated using multinomial logistic regression results providing instrumental support to peers increased the odds of complete and partial recovery from severe mobility limitation net of numerous social and health factors having relatives living nearby decreased the odds of complete recovery while being engaged in ones neighborhood increased the odds of partial recovery the influence of partner status on partial and complete recovery varied by gender whereby partnered men were more likely to experience recovery relative to partnered women the effect of neighborhood engagement on partial recovery also varied by gender disengaged women were the least likely to experience partial recovery compared with any other group discussion the rehabilitative potential of social relationships has important policy implications interventions aimed at encouraging older adults with mobility limitation to be engaged in their neighborhoods andor provide instrumental support to peers may improve functional health outcomes

introduction in this millennium era many indonesians spend their time at work and have little time to gather with their families or colleagues fenomena worklife balance kompasianacom states that in 2015 the us society for industrial and organizational psychology conducted research on employees as a result 70 of employees complained about working hours on the grounds that the duration of meeting family was shorter so that time to meet with family and social life at home was reduced from the above phenomenon it is known that work and family life in indonesia still need to be balanced when viewed from an organizational perspective employees are required to be able to balance the demands placed on family and work in this case an employee is required to have a role at work and is also required to be able to fulfill his role in life other than work such as communicating with family and other social lives so it can cause 156 this to happen work family conflict in various literature it is explained that the meaning of is a form of role conflict where a person must be able to fulfill the demands of his role as an employee and his role in familysocial life work family conflict occurs when work demands disrupt a persons role in the family the things that cause wfc can be seen from a framework calledjobdemand resources in this framework it is explained that wfc occurs because of demands at work which has a psychological impact on a person the demands of this job can be in the form of working hours that are longer than normal working hours a high workload and activities in the job that are always related todeadlines based on the model proposed by demerouti peeters and van der heijden it can be concluded that the influencedemands or demands both at work and outside of work will increasework family conflict orfamily work conflict however there are things that can weaken this influence namelyresources resources in contextjob demandresources refers to aspects of work or family that can help someone to meet the demands of work or family resources or resources in this research act as social support which can come from within work or outside work foley ngo and lui say that social support can weaken the relationship betweenjob demands to work family conflict when someone gets support from other people family or friends in facing existing work demands then that individual will be able to meet the demands that exist in the family and at work in other words when there is a family conflict that will affect work or vice versa and there are relatives or family who support or encourage the person to face those demands then the individual will be able to fulfill the demands both in work and in the demands existing in the family then it can be said that the levelwork family conflict will get lower this can happen because there is support that can help in meeting the demands that exist in each domain work family conflict high levels also have an impact on a persons level of satisfaction in this case a persons satisfaction is included in job satisfaction orjob satisfaction family satisfaction orfamily satisfaction and life satisfaction orlife satisfaction when someone experiences work family conflict high levels will have a negative effect on the persons job satisfaction as iswork family conflict will have an impact on family satisfaction in previous research conducted by howardet al indicates thatwork family conflict is associated with several negative things one of which is a low level of satisfaction with ones familythe aim of this research is to analyze kbalance between the demands of family and work respondents in the research were doctors in surabaya and its surroundings doctors are a profession that many people are interested in however most people dont understand that working as a doctor is not as easy as they imaginenationalist doctor professional challenges in the midst of a pandemic states that the medical profession is a noble profession and doctors are placed at the highest strata in terms of social statusdoctors are hard workers bergeloracom stated that work as a doctor is one of the jobs that has the highest level of stress compared to other jobs because other peoples lives depend on their skills doctors must be ready whenever patients need them as said by john w holland in his article entitleda doctordillema stating that the profession as a doctor requires great physical and mental effort because most of the doctors time is spent healing his patients as a doctor sometimes you have to give bad news about the illness your patient is suffering from and you also have to be able to deal with patients who are anxious or afraid of the illness they are suffering from so this causes the doctor to experience mental fatigue when dealing with patients the existence of relatively long and uncertain working hours sometimes means that doctors do not have enough time to rest spend time with family besides that having an inflexible schedule can make a doctor physically and psychologically tired or exhausted in completing his work so that he can causes it to existwork family conflict based on the explanation explained in the background section the problem formulation in this research is as follows 1 do job demands affect wfc 2 does wfc have an effect on family satisfaction 3 does social support moderate the relationship between job demands and wfc gambar 1 model penelitian it is hoped that this research will add to and develop research in the field of human resource management especially regarding workfamily balance it is also hoped that this research will be able to become a reference for future research especially regarding the relationship between work and family balance and the perspective oflife career stage for hospitals or other organizations that have employees who are doctors from this research managers or management who are responsible for forming policies will have an overview of the decisions taken regarding problems that have the potential to arise in doctors work and families so that in the future policies can be formed that can suppress itwork family conflict felt by the doctor members so that the doctors performance will increase literature review according to research from beutell and wittigberman it is stated that an employee is required to be able to balance the demands placed on family and work in this case an employee is required to have a role at work and is also required to be able to fulfill his role in life other than work such as communicating with family and other social lives some researchers suggest that there are 2 forms of role conflict these two roles arework family conflict dan family work conflict demerouti peeters and van der heijden stated that the two conflicts are interconnected but have different causeswork family conflict occurs when demands on work will disrupt a persons role in the family while fwc occurs when there are demands on family life that will disrupt a persons role at work in previous research conducted by howard et al indicated that wfc is related to several negative things one of which is a persons low level of family satisfaction several studies on wfc focus on finding the causes of why wfc occurs and its consequences but it is also important to know how the wfcfwc phenomenon looks like when viewed from career level or from the level of life different demerouti peeters and van der heijden stated that there are differences in the wfcfwc phenomenon when viewed from a persons career and life level demerouti et al divide a persons career and life levels into 3 groups namelyyounger employees middleaged employees andolder employees this research seeks to apply the theoretical concepts put forward by demerouti et al into empirical research the aim of this research is to analyze whether there are differences in the wfcfwc phenomenon in terms ofantecedents oroutcomes in these 3 groups job demandresources job demandresources is a model put forward by demerouti bakker nachreiner and chaufeli in this model it is stated that job characteristics are divided into two parts namelyjob demand andjob resources job demand or job demands refer to aspects of work that require physical and mental effort so that they can have an impact on the employees psychology 2001 explains thatresource can be divided into two groups external groups and internal groups the external group consists oforganizational resources andsocial resources while the internal group consists of cognitive features and action patterns in this research what is meantsocial resources is support that comes from colleagues and peer groups job demand as mentioned abovejob demand is a view of the level of demands in the work domain yang chen choi and zou also explain thatjob demand is pressure that arises from excessive workload and time pressure at the work location including workrelated busyness anddeadline ganster and fusilier also explain thatjob demand can be measured through the degree to which employees have to work hard and fast have a lot of things to do and have little time apart from workload and time pressure the acceptance of conflict from various sources can influence the activities carried out by employees and will be seen as job demands job demand is a characteristic of work that has the potential to cause tension in cases where it exceeds the employees adaptive abilities mykletun dahl moen and tell state that there are three measurement factorsjob demand firstly everyone who works is required to complete their work quickly secondly everyone who works is required to work hard and thirdly everyone who works is required to have a lot of time to complete the work work family conflict before explaining the definition ofwork family conflict it is important to note that greenhaus and beutell referring to the theory put forward by kahn wolfe quinn snoek and rosenthal in 1964 explained thatwork family conflict is one form ofinterrole conflict interrole conflict is defined as a form of role conflict where there is pressure from one domain that is incompatible with another domain by definitioninterrole conflict that thenwork family conflict is defined as a form ofinterrole conflict where there are role pressures from work that conflict with role pressures from the family then according to howard et al work family conflict is something that arises when role participation in the family is more difficult than role participation in workwork family conflict arises when a persons participation in a domain interferes with a persons ability to fulfill their responsibilities and obligations in one of those domains for example someone is said to experience work family conflict when his participation in work interferes with his ability to fulfill the responsibilities and obligations of his role at home conflicts that arise due to efforts to fulfill and balance the role demands of the family and the role demands of work are divided into two namelywork family conflict andfamily work conflict wfc is defined as a form of conflict where there is role pressure from the work domain which conflicts with role pressure in the family domain while fwc is defined as a form of conflict where there is role pressure from the family which conflicts with role pressure from work fwc can arise when participation in work roles becomes more difficult due to participation in family roles demerouti also stated that wfc and fwc are correlated but the causal factors and resulting consequences are different so it appears that the main difference between wfc and fwc lies in the domain of the pressure carlson kacmar and william state that there are five measurements that can be used to measurework family conflict firstly the amount of time spent at work second there is fatigue in doing work at work third there is stress at work fourth the attitudes applied at work are different from the attitudes applied at home lastly the attitude towards work is not suitable to be applied elsewhere social support social support or social support according to marcinkuset al defined as a relationship structure that can provide resources or support zimet gregory d dahlem nancy w zimet sara g farley gordon k explained thatsocial support is an exchange of resources between two or more people carried out to improvewellbeing from support recipients social support can come from various parties marcinkuset al say that social support can come from relationships at work or personal relationships several studies also differentiate the domain of social support into 2 namely social support that comes from work and social support that comes from a persons personal life in the work context what constitutes social support is support from superiors or the organization where employees work in the context of personal life what is meant by social support can come from a partner friends or parents marcinkuset al states that there are nine measurements to measureworkrelated social support firstly there is a flexible work schedule from the direct supervisor secondly there is mutual understanding between coworkers thirdly there is support from coworkers to carry out responsibilities within the family fourthly the availability of coworkers to carry out other work assignments or responsibilities of coworkers fifthly there is flexibility in changing schedules sixth the availability of colleagues to share experiences and understanding of life seventh organizations provide flexible work schedules eighth organizations have policies that make it easier to pay attention to family and finally there is support from the organization to carry out responsibilities within the family workrelated social support satisfaction outcomes beutell and berman explain that there are four types of indicatorssatisfaction outcomes four typessatisfaction outcomes that isjob satisfaction marital satisfaction family satisfaction andlife satisfaction however in their research kim and choo stated thatmarital satisfaction is part offamily satisfaction where marital satisfaction will refer to the quality of relationships within the family namely the relationship with ones spouse and also with children based on this thensatisfaction outcomes used in this research arejob satisfaction family satisfaction andlife satisfaction this was also done by lapierre spector allen poelmans cooper odriscoll sanchez brough and kinnunen who conducted research on testing the relationship between six dimensionsworkfamily conflict on employee satisfaction with work family and life as a whole family satisfaction family satisfaction or family satisfaction is a subjective evaluation based on a persons family life family satisfaction assesses the positive feelings felt by someone regarding their family situation family satisfaction is satisfaction that refers to the quality of relationships within the family namely relationships with partners and also with children based on the measurement items of millis grasmick morgan and wenk it can be seen that a persons satisfaction with the family can be viewed through four things the first is satisfaction with family relationships the second is satisfaction with the familys role in decision making the third is satisfaction with the familys role in difficult times the fourth is satisfaction with the familys response to current work relationship betweenjob demand terhadap work family conflict the demands at work will affect a persons wfc level ford heinen and langkamer suggest that when job demands such as long working hours strict deadline this will lead to role conflict in work and family in other words the higher the demands felt by someone in their work the higher the possibility of experiencing wfc as explained in the previous section the difference between wfc and fwc lies in their domain so if demands at work will give rise to work and family role conflict then demands in the family will give rise to family and work conflict based on this the following hypothesis can be formulated h1 job demand influence on wfc the relationship between work family conflict and family satisfaction when someone feels a high level of workfamily conflict this will affect the family satisfaction they feel based on previous research in taiwan it is known that wfc has a negative effect on job satisfaction and family satisfaction this is in accordance with the results of research conducted by ford heinen and langkamer that when a role at work interferes with the family it will reduce a persons level of family satisfaction this is because when someone experiences role conflict at work it will disrupt their role in the family the result is that work related to the household cannot be completed properly which will reduce family satisfaction based on this explanation a hypothesis can be drawn namely h2 wfc influences family satisfaction moderation relationshipsworkrelated social support to the influence betweenjob demand dan work family conflict the demands of work and family influence work family conflict but this influence can be minimized when there is social support from both work and personal marcinkuset al stated that social support can play a roleantecedent direct effects mediators and moderators marcinkuset al also stated that when employees feel that they are supported by their superiors such as being allowed to go home to care for a sick child this will reduce the negative influencejob demand against wfc employees who perceive that the company is less supportive of family matters were found to experience more wfc less job satisfaction less organizational commitment and a higher desire to leave compared to companies that provide support for family matters this relationship provides support that reducing wfc can be done by reducing time demands and stress based on this explanation a hypothesis can be drawn as follows h3 social support will moderate the relationship betweenjob demand dan wfc method this research uses a quantitative approach where research uses a quantitative approach which focuses on hypothesis testing the data used must be measurable and will produce conclusions that can be generalized explaining the phenomenon in a measurable way this quantitative research approach uses statistical partial least square there are several reasons that encourage the use of analytical toolspartial least squarefirst in this research two types of indicators were used to measure eachvariable second this research model is quite complex with the presence of mediating and moderating variables as well as grouping in the research model and finally the aim of the research is to predict the relationship betweenvariable sekaran states that the sample is part of the population by using samples conclusions will be obtained that can be used to generalize the population the technique for determining samples is calledsampling in this research techniquesampling which is used isnonprobability sampling nonprobability sampling is a techniquesampling which is used to type the probability of an element in the population being selected as a sample subject is unknown usenon probability sampling chosen because of the unavailability of access for researchers to obtainsample frame of the number of elements in the population of all types in engineeringnonprobability sampling selected typepurposive sampling which is in accordance with the research objectives according to sekaran purposive sampling needs to be done to obtain information from specific targets in this study the group that is believed to be able to provide the desired information are doctors who are married and have irregular working hours this is determined related to the existence of variablesfamily demand andjob demand where researchers have the assumption that doctors who are married and have children will experience higher demands from their families compared to doctors who are not married andor do not have children and doctors who have less regular working hours will experience higher job demands compared to those who do not have children doctors who have regular working hours based on the significance testpath coefesien the statistical data can be depicted in the picture above it is known that there is a significant influencejob demand towork family conflict with a tstatistic value of 274 andoriginal sample 1207 there is a nonsignificant effectwork family conflict tofamily satisfaction with t statistic results of 042 andoriginal sample 0049 while significant results were also obtained for the moderating effect of wrss on the relationshipjob demand andwork family conflict with a t statistic of 175 andoriginal sample amounting to 1157 results and discussion influencejob demand towork family conflict it is known thatjob demand provide a significant influence onwork family conflict h1 is accepted this means that the high workload long and erratic working hours experienced by the medical profession can result in disruption of work as a doctor and will also have an impact on interference with ones role in carrying out obligations in the family domain with the demands of work as a doctor who is required to always prioritize the health and recovery of patients it is not uncommon for problems in their work to be brought into household matters so that they can occurwork family conflict in the medical profession in other words that one of the predictors of occurrencework family conflict is existencework overload in the medical profession work overload is described as work that must be completed by someone quickly and precisely thus causing the persons fatigue and exhaustion this is also supported by cooper sloan williams 1994 who stated that the medical profession has a high level of stress compared to other jobs so that the demands of work as a doctor can interfere with home life this is supported by ford heinen and langkamer who stated that when job demands such as long working hours strictdeadline having a heavy workload continuously working under time pressure having to be able to handle the high demands of patients faced and having erratic working hours will cause it to happenwork to family conflict influencework family conflict tofamily satisfaction can be knownwork family conflict has an insignificant effect on family satisfaction this means that conflict at work which can disrupt roles in the family domain does not affect family satisfaction in the medical profession so respondents felt that their families really supported their work as doctors so that even though there were work problems that could cause conflict in the family this did not affect satisfaction with family life the family support felt by doctors mainly comes from the partner if we look at the characteristics of the respondents answers it is known that 80 of the respondent couples have jobs marshall barnett stated that couples who both work can better understand their partners position when they experience problems with their work and haveempathy high level so that they can support each other when a conflict occurs in one of the domains moderating influencesocial support on relationshipsjob demand towork family conflict based on figure 2 it is known that the original sample value has a moderating effectwork related social support towards relationshipsjob demand and wfc is 1157 meanwhile the tstatistic value of the moderation effectwork related social support towards relationshipsjob demand and wfc is 175 hypothesis 3 is accepted moderation effectworkrelated social support which was found supported by research by lu et al where support fromsupervisor able to reducework family conflict if an individual experiences problems at work but feels social support from coworkers then the pressure felt from these problems can be minimized carlson et al also added that colleagues andsupervisor able to create a positive work environment for example whensupervisor able to reduce pressure in the workplace by having light discussions regarding family problems and being flexible when an employee has a problem conclusion based on this research it is known that job demand has a significant influence on work family conflict h1 is accepted this means that the high workload long and erratic working hours experienced by the medical profession can result in disruption of work as a doctor and will also impact interference with ones role in carrying out obligations in the family domain work family conflict has an insignificant effect on family satisfaction h2 is rejected this means that conflict at work which can disrupt roles in the family domain does not affect family satisfaction

doctors are a profession that many people are interested in however most people dont understand that working as a doctor is not as easy as they imagine doctors are one of the jobs that have the highest level of stress compared to other jobs because other peoples lives depend on their skills doctors must be ready whenever patients need them therefore the aim of this research is to find out the role of moderation work related social support on relationships job demand work family conflict and family satisfaction in this research technique sampling which is used is nonprobability sampling from the whole type in technique nonprobability sampling selected type purposive sampling which is in accordance with the research objectives the sample in this study is a group that is believed to be able to provide the desired information namely doctors who are married and have irregular working hours the results of this research show that job demand provide a significant influence on work family conflict work family conflict has an insignificant effect on family satisfaction

3 family is generally believed to be the building block of chinese society in the sociological literature however there is a dearth of empirical attitudinal research into gender roles and family values over the past decades china has undergone drastic social changes including the founding of pr china reform and openingup urbanization and globalization and so on these changes raise the question of what has happened to the family in china during recent decades has it changed and if so how the changes in chinese family structure have received considerable attention from researchers ma shi li wang and tang for example have identified such trends as everdecreasing family size the decline of patrilocalism rocketing divorce rates and hence singlemotherhood and the rise of dualearner and dink families these structural changes have been interpreted as going handinhand with changes in family and gender values in china however it is far from clear whether structural change necessarily entails value shift or vice versa the research of zimmer and kwong for example demonstrates that change in chinas age structure does not prompt a similar change in filial piety also as jayakody thornton and axinn point out structural changes alone are insufficient for explaining family change across the globe their approach to understanding family change involves the study of ideational change they explore how beliefs and values interact with unique historical and cultural circumstances to reveal important variations in behavior and thought this approach emphasizes the importance of examining both variations across different aspects of family and gender values in china and also the differential effects that chinese social and cultural changes might have on family views of people of different generations geographic regions and gender previous research particularly transnational studies using data from the eass has compared family and gender values between east asian countriesregions such as japan taiwan south korea and mainland china however transnational studies have considered china as a whole instead of reflecting its internal diversity since the establishment of a socialist regime in 1949 there has been enormous social and economic change this would include the cultural revolution the great leap forward reform and openingup and the onechild policy such change has not only influenced the country as a whole but specific events and policies have affected men and women of different generations and geographic regions differently given these internal differences the notion of chinese family values in the aggregate is problematic one aim of our research is to explore variations in family and gender values in order to address the following key questions what family and gender values do people share in contemporary china how are various aspects of family and gender values perceived differently how do views differ across time place and gender 4 in the following sections we discuss the relevant background context for addressing these questions first we review the traditional basis of family and gender values in china second we present a succinct overview of the historical and policy changes in china that may influence views about family life third we introduce the theoretical and empirical literature from which we derive our hypotheses we then present our empirical analysis of the 2006 chinese general social survey and conclude by discussing the implications of our findings family and gender values in china traditions in china traditional family and gender values inform two major sets of relations within the familial system vertically intergenerational relations are regulated by filial piety and horizontally gender roles shape conjugal relations the responsibilities obligations rights and powers of family relations are further underpinned by the norm of patrilineality the malecentered line of descent the patrilineal system is key to traditional chinese family and gender values first it emphasizes the male line of descent which gives precedence to the eldest male in the family and makes a male heir vital to keep the family lineage intact second patrilineality regulates the familys economic relations in terms of inheritance in traditional china the inheritance would drip down through the family decreasing in order of priority as determined by genderage chinese tradition also prescribed a certain reciprocity the eldest male with the greatest entitlement to inherit would usually coreside with his parents in order to fulfill his filial obligations third patrilineality was key to the traditional chinese definition of family boundaries with unbroken male lineage vital to the familys survival married women were considered the property of their husbands families as in the traditional chinese proverb that ones married daughter is like the splashed water that cannot be taken back a womans husbands family was expected to take precedence over her biological family especially in the case of clashing benefits in general the central message codified by patrilineal traditions was that of obedience to ones superiors with elder andor male members deemed superior to those of younger andor female members built on the basic guidelines established by patrilineality filial piety prescribes specific relations and obligations between parents and children as indicated by the chinese terms for filial piety xiao jing or xiao shun which is expressed in two characters the concept has two distinct meanings that are complementary and consistent first xiao requires children especially adult children to reciprocate by caring for parents in later life thus parents are recompensed for their material investment in bringing up children in pre1949 china which lacked a welfare system xiao was key to the functioning of chinese families it preserved family lineage ensured childcare and most importantly preserved the security of the elderly the concept of xiao was integral to agricultural china where growing old meant the loss of production capability and elderly parents were supported materially by their children second jing or shun expresses the nonmaterial aspect of filial piety which signifies respect for and obedience to the elderly jing or shun obliged children to be thankful to their parents for bringing them up which in turn constituted the moral imperative to observe xiao in their conduct furthermore it was considered an ultimate virtue for children especially males to honor their parents by making them proud in the chinese nuclear family conjugal relations were arranged with the husband at the center of the household undertaking mainly productive activities the wifes role was complementary to facilitate her husbands productivity womens major function was reproductive that is giving birth and childrearing this division of labor was central to conventional gender roles in china the importance and particularity of economic activities relegated women and the domestic sphere to a secondary status women were associated with domestic chores and men with careerbased and productive activities thus traditional chinese family and gender values were consistent with the functionality of both the nuclear and extended family in aspects such as childrearing care of the elderly and so on meanwhile different aspects of family valuesfilial piety patrilineality and gender rolesare closely interweaved and are embedded in the socioeconomic and cultural contexts of traditional chinaparticularly the agricultural mode of production and the nonwelfare centralized feudal regime if traditional family and gender values were a consistent selfcontained system and were closely affiliated to their specific environment it makes sense to explore how resilient values are in the face of contextual shifts and whether traditional attitudes have shifted in response to social change social change in china 1949 to 2006 in 1949 the founding of pr china marked the end of a feudal history lasting for more than 2000 years thence industries and urban landscapes began to burgeon in china upholding an egalitarian ideal the socialist revolution contributed to gender equity in employment and the subversion of patriarchal traditions from 1949 to 1952 womens participation in paid labor increased from almost nil before 1949 to 74 as opposed to 87 for men from 1967 to 1977 the cultural revolution and great leap forward marked the climax of chinas socialist revolution gender equity in the public sphere and industrialization were further emphasized confucian teachings that were core to traditional chinese family values were attacked along with patriarchy the cultural revolution also had a pronounced effect on eradicating the educational privilege associated with family background by making the educational attainment of men more equitable at the same time both males and females were mobilized to rural areas for the agenda of social construction legalized in 1979 the onechild policy substantially altered the traditional family structure with nuclear 2 1 families gradually becoming the norm in china although at one time the policy was accompanied by numerous female infanticides it has been attributed with helping to undermine patrilineal norms however the onechild policy has not eroded filial piety despite changing forms of intergenerational support the impact of the onechild policy on womens roles are somewhat mixed policymakers claimed that family downsizing would liberate women from domestic duties however some scholars suggest that the policy might have led to chinese womens greater engagement in housework and childcare linking policy and gender role outcome is problematic however not least because the onechild policy coincided with reform and openingup in late 1978 reform and openingupa stateguided program for economic modernizationopened chinas market to the rest of the world as the socialist pressure relaxed it became possible for chinas culture to take its own course albeit directed by the priority of economic development urbanization and industrialization escalated and the country has been increasingly exposed to western culture due to booming commercial connections for example feminist thought became more influential and the importance of economic independence and individualism entered the discourse of gender dynamics reform and openingup although intended to bring about changes throughout the nation was in practice unevenly implemented chinas partial development in the 1980s prioritized economic construction in coastal areas big cities municipalities and provincial capitalskey strategic positions located mainly in urban china as a result these areas received the greatest exposure to western culture in an era of increasing international trade and commerce previous research has noted how this affected many spheres of life ranging from education language media and cultural activity to the consumption of daily commodities the political importance attached to development and economic success led to a valorization of urban western and global trends over their rural eastern and local counterparts consequently urban and western culture became increasingly popular in china especially among people born after the 1980s in addition to the various sociocultural changes caused by reform and openingup the hukou policychinas household registration systemincreased sociocultural division legalized in 1952 the hukou policy was designed to control population mobility and secure enough labor for each sector of production it fixed people geographically by localizing welfare packages such as unemployment subsidies medical care and so on the distinction between rural and urban hukou further exacerbated the divide between agricultural and industrial modes of production though the recent reform of the policy has since led to largescale internal migration in china family values explaining differences one of the key insights of ideational research on family change is that rather than producing uniform change as some of the globalization theorists imply the interaction of ideational forces with unique historical and cultural circumstances results in important variations it seems likely that in a country as internally varied as china there is unlikely to be uniformity in family and gender values one of our key concerns is to explore what we call ideational consistency we expect some erosion of traditional values as china has become increasingly global and open to western values since late 1978 however it is far from clear whether traditional values regarding patrilineality filial piety and gender roles would be challenged to a similar degree our brief review of traditional family and gender values suggested there were two major sets of relations within the familial system intergenerational relations regulated by patrilineal norms and the consequent material and nonmaterial strands of filial piety and conjugal relations governed by gender role norms it seems plausible in the light of existing theoretical and empirical research that gender role ideational change will vastly outpace any erosion of traditional filial piety inglehart and norris suggest that there is a rising tide of gender equality and cultural change around the world while we do not subscribe to any notion of global convergence there is evidence that china has taken steps to promote womens equality as we have seen women play an important role in the labor force despite there being no equalemployment legislation to date women have long had the right to marry who they chose and the right to divorce even though attitudes toward equality in conjugal relations lag behind but what about intergenerational relations it is arguable that in china the emphasis on subordination of the young to the welfare of their parents became elaborated to an unusual degree and that the form of family life within which socialization for filial piety occurred was distinctive during the changes since the establishment of pr china in 1949 staterun educational institutions and bureaucratic assignments to jobs and housing replaced job training and inheritance from parents but the chinese communist party has at no point systematically attempted to get young chinese to reject filial obligations in fact the reverse education in contemporary china has consistently stressed jing as a chinese virtue inculcating the moral imperatives of filial obligations empirical research seems consistently to show that filial obligations are alive and well even in urban china it is one thing to assert that an interaction of ideational forces with unique historical and cultural circumstances results in important variations it is another to specify along what dimensions these variations might be structured in this article we examine three dimensions which have received considerable emphasis in the literature on family value change following giddens we see temporality and space as crucial for understanding social change in empirical work on ideational change these dimensions can be most easily operationalized as generational and geographic variations our third dimension is gender which as therborn demonstrates is a crucial dimension of family change as sex and power are core to the changing politics of family generational difference mannheims essay on the importance of generations is a classic work about how generations underpin social change generational replacement is a key mechanism of social change whereby the stance of the public can shift as earlier cohorts with more traditional values die out and recent cohorts with less traditional values take their place to the extent that family and gender roles are changing in china we would expect to see marked generational differences in values however these are likely to vary by issue with greater generation differentiation on patrilineality and gender roles where traditional values are under increasing challenge than by filial piety where traditional values are expected to hold sway geographical difference the importance of geography in understanding family change has been emphasized again and again in crossnational research regional differences within countries have been somewhat less wellexplored in representative survey research usually because of data limitations in china there is an increasing gulf between the highly developed urban areas in the east and the rural and western regions of china however as whyte notes market reforms driven by global forces were instituted in chinese villages earlier than in the cities which may result in family continuities and changes that span rural and urban china gender difference no family research today can ignore the importance of gender as therborn indicates understanding family values means understanding sex and power in a particular cultural setting research on international differences in family values and gender roles tends to report either a surprising degree of similarity between men and women or women being more likely to challenge traditional values than men because women stand to benefit more from change there is a dearth of research on family and gender values in china and one important goal of our research is to examine whether there are consistent gender differences across the different family and value domains and also whether generation and geography interact with gender in structuring values concerned with patrilineality filial piety and gender roles women may be less traditional than men regarding patrilineality and gender roles because women have more to gain by changing the status quo however there may be little gender difference regarding filial piety because the intergenerational system of family care is one in which both women and men have invested interests hypotheses drawing on the literature and discussion of the preceding sections we propose four hypotheses as below our exploration of family and gender values will address the following three key categories patrilineality filial piety and gender roles hypothesis 1 there is no overall consistency in family and gender values regarding patrilineality filial piety and gender roles in china instead we expect patrilineal and gender role values to be less traditional than filial piety hypothesis 2 generational difference will affect family and gender values with more recent cohorts holding less traditional attitudes in particular domains hypothesis 3 people from rural and western china will have more traditional family and gender values than people from urban eastern areas hypothesis 4 women in china will hold less traditional attitudes toward certain family and gender values than chinese men methods data variables dependent variables family and gender values in china cgss 2006 measured family and gender values using 7point likerttype scales we have standardized all measures such that 1 represents the most traditional attitudes and 7 represents the least traditional attitudes toward family and gender values altogether 15 items were used to measure attitudes toward traditional family and gender values in china as presented in table 1 insert table 1 here exploratory factor analysis was used to extract our indexes for chinese family and gender values we assessed the factorability of the 15 items relating to family and gender values and found the item correlations to be reasonably high the kaisermeyerolkin measure of sampling adequacy was 076 and barletts test of sphericity was significant χ 2 105 2117325 p 001 principal component analysis and varimax rotation were used to guide computing composite scores for the indexes cronbachs alpha scores showed high consistency within each of the indexes no substantial increase in alpha for any of the indexes could have been achieved by eliminating items each index is scaled from 1 to 7 with a higher score indicating a less traditional attitude toward traditional chinese family and gender values our sample consists of 3050 cases after outliers were removed indices were within a range sufficient to assume normal distributions key predictors and covariates table 2 presents the descriptive statistics of our key predictors and covariates our key predictors are generations geographic regions and gender we coded birth cohorts into four groups based on the different historic events or periods presocialist socialist cultural revolution and reform openingup in cgss 2006 geographic regions are differentiated by the administrative and development levels as major cities eastern townsvillages central townsvillages and western townsvillages gender is a dummy variable article doi 1011770192513x14528710 given the potential influence of such important demographic and personal characteristics as marital status number of child level of education knowledge of foreign language and employment status we included these attributes as covariates education levels are grouped into primary school and below middle school high school and university and above employment is coded into a dummy variable indicating working and not working insert table 2 here analytical strategy using analysis of covariance on each aspect of family and gender values we ran three models only key predictors covariates added and interactions between generation and gender geography and gender and gender and employment added other interaction terms were not significant and are excluded comparisons across the models allow us to examine whether generational geographic and gender variations in family and gender values are explained by the addition of factors such as work education and so on results family and gender values figure 1 presents the descriptive statistics for the family and gender values first the results show that attitudes toward family and gender values in todays china generally remain traditional on the assumption that 4 the midpoint of the 7point scale of our indexes represents a neutral attitude second the findings support our hypothesis that there is no overall consistency in family and gender values insert figure 1 here our results indicate that attitudes are least traditional toward patrilineal values the detraditionalization of patrilineality however has not undermined the filial piety it once sustained attitudes toward filial piety in terms of both xiao and jing remain traditional jing the moral imperative that obliges one to be obedient and respectful to parents stays the most traditional among these measures of family and gender values attitudes to xiao material support to the elderly are also relatively traditional although responses differ depending on whether financial support is to be provided by unmarried or married children in chinese tradition unmarried children usually coreside with their parents while material support is generally expected from financially independent children 12 in contrast attitudes toward gender roles that specify relations between husband and wife are less traditional the traditional gender division of labor whereby the husbands role is to earn money and the females role is to care for her family and support her husbands career is not given overwhelming support in contemporary china multivariate analysis table 3 presents the results of the three ancova models for each of our five dependent variables in each instance the three models show main predictors predictors plus covariates and predictors covariates and interaction terms our findings indicate that generational geographic and gender variations have diverse effects on different aspects of family and gender values controlling for education matters particularly for explaining some of the generational effects the addition of interaction terms between predictors and gender somewhat improves the explained variance of the two least traditional of our dependent variablespatrilineality and gender roles however most of the variance in family values remains unexplained by these main independent variables we consider possible explanations for the low explanatory power of our models in the discussion section first however we present the findings for each of the family and gender values in turn insert figure 3 here patrilineality our results support our hypothesis that more recent cohorts hold less traditional attitudes toward patrilineal values the geographic difference hypothesis is only partly supported by our findings compared with western rural townsvillages people from the more urbanized and industrialized regions exhibit significantly less traditional attitudes toward patrilineality with the exception of eastern townsvillages the findings also support our gender difference hypothesis and show that women hold significantly less traditional attitudes than men toward patrilineality in model 1b where the covariates are included the results clearly show the importance of education in reducing traditional patrilineal beliefs people who are better educated hold less traditional attitudes toward patrilineality interestingly introducing education eliminates the observed generational effects and thus for patrilineal beliefs generational effects can be explained by education the geographic effect remains when education is included which suggests that the degree of urbanization and industrialization associated with the different geographic regions operates independently of education in influencing patrilineal beliefs in model 1c which includes the interaction terms between gender and the predictor variables we can see that females from the reform and openingup generation hold significantly less traditional attitudes toward patrilineality than men and women from other generations once interactions terms are included in model 1c gender is no longer significant filial piety our generational hypothesis is overturned when it comes to filial piety we find that the more recent generations hold more traditional attitudes toward xiao though attitudes differ between financial support from married or unmarried children the geographic effects also vary across different aspects of filial piety unlike for patrilineal beliefs there are no gender differences with respect to filial piety for xiao only the reform and openingup generation displays slightly less traditional attitudes than the earliest pre1949 cohort nevertheless even this generational effect disappears once we include covariates with married people less likely to support the view that unmarried offspring should provide financial support to parents people from central townsvillages show less traditional attitudes toward xiao than those in western towns and villages in model 2c the interaction of work and gender shows that employed women hold more traditional attitudes than either men or women who are not employed toward unmarried offspring providing financial support to parents thus financial independence of women should not be equated with more individualistic or liberal attitudesat least as far as filial piety is concerned for xiao more recent generations are significantly more traditional in beliefs that married children should provide financial support to parents while attitudes are generally consistent across geographic regions people from major cities are less traditional than western townvillages this geographic variation is further elaborated in model 3c which includes the interaction of gender and geographic regions model 3c shows that women living in major cities hold significantly less traditional attitudes toward the practice of financial support for parents than do those living in other regions the results for xiao echo those for xiao marriage predicts less traditional attitudes and employed women hold more traditional views about supporting parents financially people who are relatively highly educated also display a stronger traditional support for xiao our results do not support the generational hypothesis for jing instead we find that the moral imperatives for filial piety remain strong and highly consistent across generations people from eastern townsvillages show significantly more traditional attitudes toward jing though ideations are by and large consistent across geographic regions as is the case for xiao the results suggest that higher education reinforces the moral imperatives for filial piety gender roles the reform and openingup generation is by far the least traditional when it comes to gender roles which is in accordance with our generational hypothesis there are also marked geographic differences with those in major cities and central towns least likely to hold traditional gender role beliefs in model 5b our findings suggest that the generational effect is largely explained by the inclusion of the number of children education and knowledge of a foreign language people with more than one child display more traditional attitudes toward gender roles than those who have no children or one child thus our findings are consistent with those who suggest that the onechild policy might help endorse more egalitarian gender role beliefs however this interpretation is speculative in part because family planning policy is unlikely to be solely responsible for singlechildren households we find that people who have received higher education hold significantly less traditional attitudes toward gender roles we also find that people who have knowledge of a foreign language hold less traditional gender role attitudes one possible interpretation is that education and familiarity with other languages might increase exposure to western culture and feminist ideas the results from model 5c show that it is women from the reform and openingup generation who are significantly less traditional than men and women from other generations in gender role attitudes this is similar to our finding concerning patrilineal beliefs in addition employed women hold less traditional attitudes to gender roles than employed men or those who are not currently employed interestingly when the gender and generation interaction is included the coefficient for gender is negative indicating that women in general are not less traditional than men thus our gender hypothesis is only partially supported for gender role beliefs discussion and conclusion previous research has focused on changes in chinese family structures citing family downsizing the decline of coresidence falling marriage rates and rising divorce rates some researchers have inferred that family and gender values are changing rendering many traditional views outdated in todays china how accurate are these inferences the results of our analysis of family and gender values indicate that such claims are only partially supported in general traditional family and gender values are still quite widespread in contemporary china in particular our respondents strongly endorsed filial piety in its components xiao and jing however attitudes toward patrilineal beliefs and gender roles prescribing a traditional gender division of labor had significantly less support thus the demise of traditional views in one dimension of family and gender values does not imply a similar questioning of traditional values in other dimensions we concur with the ideational approach to family research that insists that structural changes alone are insufficient for explaining family change this approach expects beliefs and values to vary with unique historical and cultural circumstances thereby revealing important variations in behavior and thought the ideational approach questions the transnational family research that has examined chinese family values in the aggregate in the light of historic events such as the founding of chinas socialist regime cultural revolution and openingup the introduction of hukou and onechild policies it is likely that chinese social and cultural circumstances might differentially affect the views of people of different generations geographic regions and gender we find considerable diversity in the way that generations geographic regions and gender help structure the distinctive family and gender values associated with patrilineal beliefs filial piety and gender roles interestingly women of the reform and openingup generation display least support for patrilineal beliefs there are also clear geographic differences between the western towns and villages who adopt a more traditional stance and the central and metropolismajor cities that are less traditional education also matters in eroding support for traditional patrilineal beliefs however these same patterns do not carry across to filial piety where traditional values hold sway in terms of both material support and nonmaterial obligations to parents in chinese tradition unmarried children usually coreside with their parents whereas material support is generally expected from financially independent children thus it is no surprise that the traditional obligations of xiao are supported more strongly than for xiao however for both higher education and female employment are associated with more not less traditional beliefs thus one cannot infer a liberating effect of education or female employment across chinese family and gender values education and female employment do reduce traditional support for patrilineal beliefs but they have the opposite effect for filial piety as measured by xiao education also increases support for traditional filial piety as measured by the nonmaterial jing when it comes to gender roles we have somewhat more expected findings education enhances peoples endorsement of less traditional attitudes and so does female employment women particularly from the most recent cohort are most likely among the generations of both sexes to endorse less traditional views knowledge of a foreign language also decreases support for the traditional gender role divide not surprisingly people with multiple children are more likely than those with one or no child to endorse traditional gender roles our findings on gender roles are similar to findings in western research that more recent generations higher education womens employment and smaller family size reduce support for traditional gender roles models including such explanatory variables in western cultures could be expected to explain up to one fifth of the variation in gender role beliefs however in china family and gender values are not highly differentiated by the social and demographic characteristics that are commonly used by social scientists in their explanatory models one possible reason might be that china is bureaucratically controlled to a far greater extent than the developed countries of the west thus other factors such as personal networks and bureaucratic position might be more important indicators unfortunately we are unable to test such suppositions even income although included in the survey has major problems with missing data and has had to be excluded from our analysis moreover our categorization of generations and geographic regions is necessarily crude given the differential impact that chinas farreaching programs of social and cultural change are likely to have had on family and gender values family values in china have undoubtedly been guided by the familism rooted in confucian teachings however even in this limited crosssectional analysis of chinese general social survey we have established that the chinese do not cling to traditional views in all domains patrilineal beliefs and traditional gender roles are being questionedand education female employment and the individualism associated with city lifeare likely to erode traditional beliefs still further so why does filial piety seem relatively resilient to change our data do not allow us to give any definitive explanations however neither education nor urbanization is undermining filial piety or at least not yet why the argument that whyte puts forward is that support for filial obligations are alive and well in urban china because the nature of the urban social order constructed in the maoist era and continued in the present era supported those obligations in multiple ways while making them fairly nononerous for grown children similarly zimmer and kwong suggest that population aging is not shifting filial piety beliefs or behavior as much as might be expected whatever the explanation it seems clear from our analysis is that in china complex adjustments in family values are occurring with traditional views challenged more in conjugal than in intergenerational relations the primary purpose of this research is not to challenge modernization theory in part because of the limitations of our data set however our results might imply that some reconsideration of modernization theory is needed for example goode suggests that the underdeveloped countries of the world would eventually make a transition from traditional to modern in a fashion similar to the transition that had occurred in the west goode predicted that as industrialization spread the worlds family pattern should converge to the western conjugal family model fifty years on since goode predicted a global convergence trend our results demonstrate the distinctive complex national context effects in china on differing family and gender values such contextual differences merit further exploration in future research predictions about future family change in china are meaningless without good data to follow through on this base line study we need comparable measures going forwards ideally we also need longitudinal data to unpack individual change across time with the vast internal migration flows and the dramatic changes in family policy it remains an ongoing challenge to understand how the changing circumstances of husbands and wives and parents and child influence traditional family and gender values author accepted manuscript

previous research has reported on structural changes in chinese families however questions remain as to whetherhow social change has influenced family and gender values and how this differs across generations regions and gender in china drawing on 2006 data from the china general social survey we find that values pertaining to filial piety are traditional whereas patrilineal and gender values are less traditional historic events policies provide the context for how social change can shape differential generational geographic and gender perspectives our hypothesis that generation region and gender associations will differ across the various ideational domains is confirmed we find significant interaction effects in how generation and geography differ by gender in patrilineal filial piety and gender values and higher education erodes patrilineal and traditional gender values but enhances filial piety such findings indicate that family values should be understood in the specific sociocultural contexts governing chinese families across time and place

how catholics sometimes talk about natural family planning the catholic church has come to teach that the use of natural family planning by married couples to avoid procreation is morally acceptable for iustae causae just causes in the words of pope paul vis encyclical humanae vitae and the catechism of the catholic church 1 this raises two questions first what sorts of causes would qualify as just ones second if a couple were to use nfp to avoid procreation without a just cause then how should their attitude toward sexuality and procreation be described with regard to the first of these questions it seems somewhat common to hear good catholics interpret just causes rather narrowly often by saying that only grave reasons for avoiding procreation will qualify as just causes this is understandable english translations of some key church documents sometimes use the expression grave reasons one can point to the influence of this interpretation both in the midtwentieth century when the rhythm method was newly developed and today in the second issue of the linacre quarterly in 1933 ethicus wrote on the one hand that if the motive for family limitation is a good motive such as well might be in these times present and overburdening economic difficulties then the use of the safe period is not evil from the purpose and intention of the agent this so far would not seem to be an especially narrow understanding of what would constitute a morally sufficient reason for the use of what is now called nfp to avoid procreation on the other hand however ethicus then adds this very significant caution all the moralists deprecate and warn against the broadcasting of these matters all this concerns individuals information advice direction should be given by individuals to individuals why the use of the safe period is evidently open to abuse it can be a great danger to married people childless marriages to indicate one danger frequently end in divorce 2 it should be noted that childless marriages are but one danger that leads ethicus to be concerned about the prospect of abuse of nfp by married couples one might reasonably conclude that he also thinks that some couples if imprudently provided with information about nfp will have some children but nevertheless also avoid procreation at some times without sufficient reason ethicus reiterates and further emphasizes this caution in a subsequent article later in the same year 3 hence ethicus might be an early example of the view that there is great reason to worry about abuse of nfp in other words of something at least pointing in the direction of the grave reasons interpretation not all mentions of nfp in the early issues of the linacre quarterly included and emphasized this sort of caution 4 nevertheless the approach that places significant and special emphasis on this caution has remained influential among some catholics including philosophers and theologians attempting to offer guidance regarding nfp brian harrison a professor of theology at a catholic seminary has emphasized the expression grave reasons in his response to catholic traditionalists who are entirely opposed to the use of nfp 5 taylor marshall a catholic philosophy professor has used both the adjectives serious and grave but seems to interpret serious as meaning grave ie especially serious as when he gives as examples of medical reasons for avoiding procreation those in which the mothers or babys life would be in jeopardy speaks of grave poverty as an economic reason or refers to social reasons as serious problems in which raising children would be almost impossible 6 i can testify that this approach likewise influences some serious catholics other than academics i have been teaching for thirteen years at a catholic university that takes its catholic identitymission seriously and whose students generally come because they want to be good catholics and to be formed by a university with a strong sense of catholic identitymission each year i teach an introductory moral theology course and a seniorlevel course on sexual and medical morality in both of these courses i spend some time on catholic teaching regarding marriage sexuality and procreation i have observed that more than a few students come to these courses with the view that the use of nfp to avoid procreation is permissible only for a rather narrow range of grave reasons with regard to the second question raised by the churchs teaching that the use of nfp to avoid procreation is permissible for just causeshow should one describe the attitude of a couple who uses nfp to avoid procreation with a lessthanjust causeit seems similarly common to hear catholics refer to this attitude as a contraceptive mentality this is true even among those who do not interpret just causes narrowly christian brugger in the context of a helpful analysis of the meaning of just causes argue s that practicing nfp in a way faithful to the norms of conscia paternitas taught in humanae vitae is not expressive of a contraceptive mentality even when used to avoid getting pregnant 7 does brugger mean that using nfp to avoid procreation when responsible parenthood does not require this is expressive of a contraceptive mentality in a later article brugger contends that this would be primarily a matter of selfishness but adds that their frame of mind might be characterized by what john paul ii called a contraceptive mentality 8 hence brugger does seem to see a possible link between inappropriate use of nfp and a contraceptive mentality the suggestion that there is such a link is like the interpretation of just causes as grave reasons one that i have observed to be influential among good catholics in general for example my students i would like to reexamine and suggest a critique of the expressions grave reasons as an interpretation of just causes and contraceptive mentality as a description of the attitude that underlies use of nfp for avoidance of pregnancy without a just cause i would like to propose that serious reasons with serious understood fairly broadly is a better interpretation of just causes and that selfishness is a better term for the attitude that leads to inappropriate avoidance of pregnancy my argument regarding serious reasons will be based on a look at the terminology used in several key magisterial texts my argument regarding selfishness will take into consideration the meaning and significance of the view that contraception and nfp are distinguished primarily as fundamentally different kinds of acts that is in their moral objects i shall also give attention to what pope john paul ii means by contraceptive mentality 9 that the distinction between grave and serious reasons is of practical relevance goes i assume largely without saying it is likewise of practical pastoral importance that we not abuse the expression contraceptive mentality by using it to refer to the attitude that leads to the abuse of nfp because i suggest doing so makes it more difficult to see that nfp is different from contraception and therefore can when used for just reasons be morally good as well as that the proper attitude for martial couples in relation to procreation is one of prudent generosity i shall develop these practicalpastoral points a bit more in the conclusion to this essay nfp and serious reasons a key papal text that likely plays a significant role in giving rise to the view that nfp may not be used to avoid pregnancy without grave reasons with this expression narrowly understood is pope pius xiis discorso alle partecipanti al congresso della unione cattolica italiana ostetriche often called in english his allocution to midwives 10 in pope piuss treatment within this discourse of what later came to be called nfp he uses three times the italian word that has grave as its english cognate to refer to the sorts of reasons that justify nfp use to avoid procreation gravi motivi grave motivo gravi ragioni the english translation that i have cited accordingly translates gravigrave as grave in each case first however it may reasonably be asked whether grave is the only good english translation or even the best one for grave it might be noted that these italian and english words both come from the latin gravis meaning weighty or heavy 11 one can compare another related word that will be familiar in a medical or healthcare context gravid meaning pregnant that is heavy with child hence if etymology is to be considered then one might reasonably entertain the conclusion that the italian grave could and even should be understood as meaning a reason that is weighty or serious in a broad sense as distinguished from light or trivial rather than necessarily as serious in a only narrow sense of that term as superserious and indeed a major italianenglish dictionary indicates that while grave can mean grave it can also mean serious or heavy 12 second it is perhaps not always recognized that pope pius also speaks of seri motivi serious motives even if grave is to be translated as grave it is all the more clear that seri ought to be translated as serious the question then arises is gravegrave to be interpreted in the light of seriserious or vice versa in other words is pope pius speaking of a broader or a narrower range of reasons this question is answered by noting that pope pius refers more fully to seri motivi come quelli che si hanno non di rado serious motives such as those which not rarely arise evidently he means serious to be interpreted at least somewhat broadly rather than as signifying only a narrow range of reasons which precisely as narrow would occur more rarely this stands in contrast with and seems to rule out the interpretation of serious as meaning grave in a narrow sense of the latter term third pius xii makes a more explicit statement to the same effect referring back to and hence evidently providing his own interpretation of his allocution to midwives less than a month later in his address to the national congress of the family front and the association of large families 13 he says that nellultima nostra allocuzione sulla morale coniugale abbiamo affermato la legittimità e al tempo stesso i limitiin verità ben larghidi una regolazione della prole in our last allocution on conjugal morality we have affirmed the legitimacy and at the same time the limitsin truth very wideof regulation of offspring using nfp his uses in the allocution of the expressions grave and seri then are to be taken in a very wide sense such as might be captured by the english word serious not in a narrower sense such as would probably typically be connoted and even denoted by our word grave probably the most important magisterial text on the topic of contraception and nfp is paul vis humanae vitae as mentioned at the beginning of this essay pope paul refers to the need for just causes for avoiding pregnancy using nfp does he himself give any further guidance to be considered together with pius xiis regarding the interpretation of just causes in the english translation on the vatican website the encyclical refers to those who for serious reasons and with due respect to moral precepts decide not to have additional children for either a certain or an indefinite period of time how should serious be interpreted here first it seems appropriate to try to read humanae vitae in continuity with pope pius xiis teachings and hence to take serious in a very wide sense second the official latin has seriis causis whatever one thinks regarding how the latin gravis should be translated where it occurs in catholic teaching on this subject it is not the word used here and grave understood as meaning something narrower than serious is not the correct translation from the latin at least one translation of humanae vitae has used grave at this point 14 this is likely because the encyclical was originally composed in italian and french 15 and the words used in these languages are gravi and graves respectively however first as explained above these words and their other cognates in latin and the romance languages do not necessarily mean something strongernarrower than the various cognates for serious do second in any case the latin version even though not the original one is the official text and interpretation and translation into other languages needs to refer above all to the latin hence serious is indeed the best word to use in an english version of the relevant passage and this interpretationtranslation indicates that pope paul vis teaching on the matter of reasons for avoiding pregnancy using nfp harmonizes easily with pope pius xiis as i have explained it finally there are two texts of blessed john paul ii that provide still further guidance regarding the interpretation of what the church especially in pius xiis allocution and paul vis encyclical has taught regarding just reasons for avoiding pregnancy the first of these is in pope john pauls apostolic exhortation on the role of the christian family in the modern world john paul includes a section on preparation for marriage 16 which he teaches includes three main stages remote proximate and immediate preparation he explains remote preparation begins in early childhood next proximate preparation from the suitable age and with adequate catechesis involves a more specific preparation for the sacraments lastly the immediate preparation should take place in the months and weeks immediately preceding the wedding in connection with the socalled premarital enquiry required by canon law what is significant here is that it is the proximate preparation that pope john paul teaches should encourage people to study the nature of conjugal sexuality and responsible parenthood with the essential medical and biological knowledge connected with it hence on the one hand and as would be suggested by common sense john paul does not say that the knowledge connected with what we typically call nfp should be taught in early childhood on the other hand however he teaches that it ought to be learned sometime before the immediate preparation for marriage sometime before the months and weeks immediately preceding the wedding sometime before what most of us probably have in mind when we speak of marriage preparation it ought to be learned as part of the same stage of preparation for marriage that also includes such topics as the following marriage as an interpersonal relationship of a man and a woman that has to be continually developed correct methods for the education of children and will assist them in gaining the basic requisites for wellordered family life such as stable work sufficient financial resources sensible administration notions of housekeeping the conclusion that might reasonably be drawn is that in john paul iis mind the knowledge connected with the use of nfp as part of responsible parenthood is approximately as basic and important for married couples as is knowledge regarding such matters as the continual development of their spousal relationship the education of children work and the like this is not to suggest that john paul ii thinks that every couple will actually need to practice nfp to avoid procreation for a time at some point during their fertile years or even that as many couples will need to do this as need to say educate their children still there is a rough even if not exact equivalence 17 but if this is so then the range of reasons that justify practice of nfp to avoid procreation must be in pope pius xiis words very wide the second relevant text from pope john paul ii is an angelus address on conjugal love openness to life and responsible parenthood john paul teaches that in regard to procreationparenthood spouses must be inspired non dallegoismo né dalla leggerezza ma da una generosità prudente e consapevole not by selfishness nor by carelessness but by a prudent and conscious generosity 18 what is striking is that in formulating the churchs teaching on this occasion and one may assume that this formulation is indeed intended to convey the same substance as is found in the teachings of pius xii and paul vi john paul does not seem to think it entirely necessary to use words like grave or serious on the one hand spouses must not be selfish they must not avoid procreation simply in order to maximize their own physical psychological material or social pleasure on the other they are to avoid that leggerezzathe word comes from leggero light in weight and indicates a kind of mental flightiness or thoughtlessness 19 or carelessnessthat does not give real or one might say serious consideration to the question of whether it would at a particular time be in keeping with the genuine good of the family as a whole including the prospective child for the spouses to act in such a way that procreation would be a likely outcome on the one hand they are to practice generosity giving of themselves in ways that may be really sacrificial on the other this generosity is to be prudent taking into account their circumstances and avoiding actions that might be destructive of the family members genuine good as long as they are being truly prudent rather than selfish they are doing what is virtuous and good as long as they have a weighty or serious rather than trivial or selfish reason for avoiding procreation they may do so 20 nfp and selfishness the contrast between just and selfish use of nfp to avoid procreation that i have drawn from blessed john paul ii takes us to the second question that i would like to address in this essay should the use of nfp without a just or serious reason that is the selfish use of nfp be linked with the notion of contraceptive mentalityor as i suggest should it simply be described as selfishness in order to begin answering this question i wish to consider first what is meant by contraception as distinct from nfp obviously contraception but not nfp seeks to minimize the fertility of acts of marital intercourse in which couples engage i think that it is helpful to relate this understanding of the difference between contraception and nfp to what the church teaches regarding the components and sources of the morality of human actions in general according to catholic teaching there are three such components sources object intention and circumstances 21 in order for an action as a whole to be morally good all three of these must be good this analysis is rooted especially in the thought of st thomas aquinas 22 now it has generally been understood that the difference between contraception and nfp is one of object not intention andor circumstances it is possible that a given contraceptionusing couple will differ in their intention andor circumstances from a given nfpusing couple but this is not inevitable nor when it is the case is it the difference that makes the one couples act an act of contraception and the others an act of nfp one sees this connection between contraception or nfp on the one hand and object on the other drawn implicitly by ethicus who though he does not use the term object does explain that the difference between contraception and nfp is not one of circumstances andor intention 23 the contemporary magisterium refers to contraception as intrinsically evil 24 this likewise links contraception with moral object since the meaning of intrinsically evil acts is acts that are evil on account of their very object and quite apart from the ulterior intentions of the one acting and the circumstances 25 fully to understand the meaning of contraception then it is necessary to consider what is meant by object as distinct from circumstances and especially from intention this has been a somewhat vexed question among specialists in thomistic catholic ethical theory and fundamental moral theology in recent decades the complexity results at least partly from the fact that the latin word obiectum was quite new in aquinass day so that aquinass use of it does not occur in the context of anything like a longsettled clearspecific understanding of its meaning 26 moreover aquinas himself uses the word frequently and sometimes in what appear to be different ways probably the most thorough study of aquinass use of the word in contexts that include his action theory is that of joseph pilsner who concludes that aquinas uses it to refer to the aspects of an action that enable it to be compared to right reason andor to an actions proximate as distinguished from remote end that is to an end that is sought for the sake of some further end 27 an object then would be something that is in a certain sense within an action despite this some scholars have with some plausible justification in aquinas taken object to refer to that external element one might say to which an action is directed or put differently to the key moral element of the situation in which the action is taking place 28 whatever meaning or range of meanings object has in aquinas in contemporary catholic teaching especially as this has been elaborated developed in pope john paul iis encyclical on fundamental moral theology veritatis splendor the word refers to a freely chosen kind of behaviour the proximate end of a deliberate decision which determines the act of willing on the part of the acting person 29 it is not a feature however morally relevant of the situation in which an action takes place it is a part of the action a further question regarding the meaning of object remains however does one determine the object of an action by considering the acts natural purpose or by considering its relationship to the intellectwill of the agent the former position identifying object with the natural finis operis is a traditional thomistic one and is still maintained by some influential catholic scholars ethicus when referring to the component of an action that is distinct from intentioncircumstances uses such expressions as the natural tendency of the act itself the natural end of the married couples activity the end of the act 30 much more recently steven long among others links object with an acts natural teleology 31 others however drawing from both aquinas and pope john paul ii have understood object as referring to an act considered not insofar as it has the natural tendency to produce a range of effects but rather insofar as it is able to bring about the further end that is intended by the agent in fact john paul writes in order to be able to grasp the object of an act which specifies that act morally it is therefore necessary to place oneself in the perspective of the acting person by the object of a given moral act then one cannot mean a process or an event of the merely physical order to be assessed on the basis of its ability to bring about a given state of affairs in the outside world 32 germain grisez has suggested this understanding of object relating the term to the intentional structure of the action 33 martin rhonheimer has argued at length over a period of years for something like this understanding 34 christopher kaczor has taken a similar approach 35 in short to summarize very briefly this position object refers to the act itself that is chosen by the acting person the act that is insofar as it is able to bring about the further end that is intended by the person how does this understanding of object help to clarify the meaning of contraception as distinct from nfp again a contracepting couple chooses to minimize the fertility of the martial intercourse in which they engage they choose in other words some act that will have this consequence and precisely insofar as the act will have this consequence the act of minimizing the fertility of their engaging in intercourse considered precisely insofar as it is an act of minimizing the fertility of their engaging in intercourse constitutes the object of their action as a whole and defines that action as contraception the couple will obviously have some further intention in view something further that they hope to accomplish by means of their act of minimizing the fertility of the intercourse in which they engage they may intend to maximize the likelihood that the woman will remain able to fit into certain fashionable articles of clothing they may intend to maximize the likelihood that she will avoid serious negative health consequences that would in her case result from pregnancy they may intend to maximize the likelihood that the man will be able to afford an expensive luxury car they may intend to maximize the likelihood that they will be able to continue to provide basic and decent food for themselves and their other children any of these intentions are however precisely intentions as distinguished from the object of their action again they have nothing to do with the definition of their action as one of contraception whether or not their intention is to avoid a serious evil and thus realize a serious good whether or not it is one that might morally justify avoiding procreation and the possibility of using contraception with a good intention is acknowledged by pope paul vi and pope john paul ii 36 their act remains one of contraception what then would a contraceptive mentality in the precise sense be it would be i think a mentality that approves of the choice to minimize the fertility of the intercourse in which a couple engages as a means to accomplishing in turn some further intention what this further intention might be in a particular case and whether it would be selfishevil or prudentgood in a particular case is not relevant to the question of whether the mentality which approves of the use of a vasectomy or anovulant pills or condoms or the like in order to accomplish the intention is a contraceptive mentality now again nfp differs in object from contraception the object of an nfpusing couple is the avoidance of intercourse during the fertile times precisely because the fertile times are fertile in other words insofar as this avoidance of intercourse is likely to accomplish the avoidance of procreation they will of course want to accomplish some further end in turn by means of this avoidance of procreation but their further intention whether it is good or selfish is irrelevant to whether the object of their action is nfp however selfish their further intention might be it cannot transform the act itself that they are choosing the object of their action into contraception and if contraception denotes an object then it follows i think that contraceptive mentality ought to be reserved for a description of the mentality that is a constitutive element of this object of contraception specifically that is of the mentality that it is permissible to minimize the fertility of an actually engagedin act of intercourse however selfish the mentality might be that motivates a couple to use nfp since it is not the attitude that necessarily expresses itself in contraception it would not be accurate to call it a contraceptive mentality it should instead be called simply selfishness or a selfish mentality it remains to examine pope john paul iis use of contraceptive mentality and of another similarrelated expression and to consider the relationship between his understanding and the one that i have offered john paul says that the contemporary situation includes the appearance of a truly contraceptive mentality and adds at the root of this and other negative phenomena there frequently lies a corruption of the idea and the experience of freedom conceived not as a capacity for realizing the truth of gods plan for marriage and the family but as an autonomous power of selfaffirmation often against others for ones own selfish wellbeing 37 in a later document john paul states that despite their differences of nature and moral gravity contraception and abortion are often closely connected as fruits of the same tree i n very many instances such practices are rooted in a hedonistic mentality unwilling to accept responsibility in matters of sexuality and they imply a selfcentered concept of freedom which regards procreation as an obstacle to personal fulfilment the life which could result from a sexual encounter thus becomes an enemy to be avoided at all costs and abortion becomes the only possible decisive response to failed contraception 38 in this second text john paul does not use the precise expression contraceptive mentality he speaks rather of a hedonistic mentality still he says that this mentality often underlies both contraception and abortion and could be called the tree of which both contraception and abortion are fruits insofar as this mentality is linked with contraception and also insofar as it is linked with what seems to be the same selfish understanding of freedom with which the contraceptive mentality too is linked it seems plausible to regard this hedonistic mentality as equivalent to a contraceptive mentality pope john paul seems to think that there is a difference between this hedonisticcontraceptive mentality and the selfish but noncontraceptive mentality that might sometimes motivate the use of nfp he writes that the couple who have recourse to the natural regulation of fertility can lack valid reasons this however constitutes a separate ethical problem from that of contraception 39 but what is the difference it is i suggest as follows the choice to use contraception is morally evil especially because it is alreadyregardless of further intentiona choice to treat ones spouse as a mere means as an object to be used for the maximization of ones own sexual pleasure rather than a personal subject to be loved and hence to treat her hedonistically and selfishly 40 john paul ii works out this position in his prepapal writings 41 and these are likely key background for what he says about contraception as pope 42 but this is not true of the choice to avoid procreation using nfp the very fact that a couple uses nfp with the sacrifice of what would otherwise be some opportunities for sexual pleasure that this entails means that they are not treating each other as sexual objects as is necessarily the case when a couple uses contraception with its inherent choice to maximize sexual pleasure their most basic attitudementality toward each other remains not one of objectificationuse or hedonismselfishness it remains instead a selfgiving and loving attitudementality and this still remains the case even when choice of nfp is made in order to accomplish a selfish further motiveintention 43 this is not to deny that in john pauls mind there could potentially sometimes be a problem with the basic attitude of an nfpusing couple he offers the observationcaution that humanae vitae places the ethical dimension of the problem in the foreground underlining the role of the virtue of temperance rightly understood in the area of this dimension there is also an adequate method of acting in the common way of thinking it often happens that the method detached from the ethical dimension proper to it is applied in a merely functional and even utilitarian way when one separates the natural method from the ethical dimension one no longer sees the difference between it and the other methods and one ends up speaking about it as if it were just another form of contraception 44 two things are to be noted about this passage first it is at least possible that the common way of thinking about nfp is to be understood primarily as the way of thinking that leads to the choice of contraception instead of nfp it might sometimes be associated with the choice to use nfp as perhaps in the case of couples who object only on health grounds to surgical sterilization or hormonal contraceptives although it would not be surprising if at least some such couples while determining their fertility in the same ways as nfp users engaged in intercourse using barrier contraceptives during the fertile times 45 second in any case this way of thinking as described by pope john paul does not seem to have anything to do with whether a couples further motive intention in using nfp is selfishevil rather than good it has to do rather with their way of thinking about the method itself conclusion i have argued that two somewhat common ways of thinking speaking among good catholics should be modified the just reasons that are needed for morally good use of nfp to avoid procreation should be described as serious reasons not grave reasons when selfish motives lead a couple to use nfp to avoid procreation this should be called simply selfishness not a contraceptive mentality as i suggested above in introducing this thesis these modifications are both of practical not merely academic importance couplesfamilies will be hurt andor will come to ignore church teaching regarding sexual morality if they are given mistaken counsel to the effect that their genuinely serious reasons for avoiding procreation using nfp are not serious enough because they are not grave the churchs urgent and cogent message about the basic moral difference between contraception and nfp will be obscured and likewise dismissed if the term contraceptive is misapplied one can explain the pastoral importance of using selfishness rather than contraceptive mentality to describe the use of nfp without a serious motive in another way also as i noted above the church speaks of prudent generosity as the correct term for the morally good attitude toward procreation with blessed john paul ii we should perhaps want to point couples in the direction of this attitude thereby offering them positive and not merely negative advice regarding the attitude that they ought to have since there is a clear and obvious relationship of contrast between selfishness and generosity the use of selfishness to refer to the wrong attitude could also help point couples in the direction of seeing generosity as the morally right one for these practical reasons i propose that talking about nfp in a way that accurately presents the churchs consistent teaching about its nature and use is an essential component of our mission to participate in the building of a culture of life love and holiness 46 notes 1 pope paul vi humanae vitae n 16 catechism of the catholic church n 2368 church documents referred to in this essay are available in their original languages and english translation on the vatican website except where otherwise indicated 2 ethicus the morality of the use of the safe period linacre quarterly 1 26 3 ethicus publicity and the safe period linacre quarterly 1 6167 4 for example rev joseph reiner sj former dean of loyola university at chicago pointed out that if a married couple had an honorable motive and sufficient reason they may take advantage of the periods of sterility it is hoped that a reliable physiologic or biologic method for controlling reproduction will soon be worked out 5 brian w harrison is natural family planning a heresy living tradition 13 6 taylor marshall you can only use nfp for serious reasons what are these reasons canterbury tales blog blogspotcom201202youcanonlyusenfpforgravehtml 7 e christian brugger nfp responsible parenthood and the concept of justa causa in humanae vitae linacre quarterly 75 314 8 e christian brugger just cause and natural family planning zenit 9 this essay further expands upon and develops aspects of the argument in richard j fehring and kevin e miller is it possible for nfp to be used with contraceptive intent linacre quarterly 78 8690 i might add that the decision by the cmalinacre quarterly to print our response to this question as part of a section on frequently asked questions would seem to constitute further evidence that more than a few catholics share the view that the use of nfp with a contraceptive mentality is a significant concern and perhaps also that the overuse of nfp for avoiding pregnancy is likewise a significant concern 10 english translation available at library papaldoc p511029htm cf eg marshall you can only use nfp for serious reasons which refers to this text in particular 11 charlton t lewis and charles shorts latinenglish lexicon sv gravis 12 harpercollins italian dictionary sv grave 13 english translation in moral questions affecting married life 2429 the translation above of the relevant passage is mine 14

this essay argues through a close reading of relevant magisterial texts in the areas of sexual morality and of fundamental moral theology that contrary to opinions sometimes expressed by orthodox catholic thinkers and internalized by good catholics the churchs teaching that the use of natural family planning nfp to avoid procreation is permissible for just causes should be interpreted as requiring married couples to have serious but not grave reasons for avoiding procreation and the use of nfp to avoid procreation when a serious reason is lacking should be described as involving selfishness not as reflecting a contraceptive mentality translating latin and italian terms correctly with some help from their context confirms that just causes are serious not grave reasons attention to the churchs use of contraception to refer to the object not the intention of an action serves as the primary basis for the conclusion that there remains a fundamental difference between contraception on the one hand and the selfishly motivated use of nfp on the other